Clinical practice guidelines in pediatric and newborn medicine: implications for their use in practice

Reviewing clinical guideline development tools: features and characteristics

BACKGROUND

To improve consistency and streamline development and publication of clinical guidelines (GL), there is a need for appropriate software support. We have found few specific tools for the actual authoring and maintaining of GLs, and correspondingly few analyses or reviews of GL development tool functionality. In order to assist GL developers in selecting and evaluating tools, this study tries to address the perceived gap by pursuing four goals: 1) identifying available tools, 2) reviewing a representative group of tools and their supported functionalities, 3) uncovering themes of features that the studied tools support, and 4) compare the selected tools with respect to the themes.

METHODS

We conducted a literature search using PubMed and Google Scholar in order to find GL development tools (GDT). We also explored tools and Content Management Systems (CMS) used in representative organisations and international communities that develop and maintain GLs. By reading a selected representative group of five GL tool manuals, exploring tools hands-on, we uncovered 8 themes of features. All found tools were compared according to these themes in order to identify the level of functionality they offer to support the GL development and publishing process. In order to limit the scope, tools for designing computer-interpretable/executable GL are excluded.

RESULTS

After finding 1552 published papers, contacting 7 organizations and international communities, we identified a total of 19 unique tools, of which 5 tools were selected as representative in this paper. We uncovered a total of 8 themes of features according to the identified functionalities that each tool provides. Four features were common among tools: Collaborative authoring process support, user access control, GL repository management, electronic publishing. We found that the GRADE methodology was supported by three of the reviewed tools, while only two tools support annotating GL with MeSH terms. We also identified that monitoring progress, reference management, Managing versions (version control), and Change control (tracking) were often the missing features.

CONCLUSION

The results can promote sector discussion and eventual agreement on important tool functionality. It may aid tool and GL developers towards more efficient, and effective, GL authoring.

Dynamic evolution of practice guidelines: analysis of deviations from assessment and management plans

OBJECTIVE

A Standardized Clinical Assessment and Management Plan (SCAMP) standardizes the care of patients with a predefined diagnosis while actively inviting and collecting data on clinician deviations (DEVs) from its recommendations. For 3 different pediatric cardiac diagnoses managed by SCAMPs, we determined the frequency of, types of, and reasons for DEVs, which are considered to be a valuable source of information and innovation.

METHODS

DEVs were collected as part of SCAMP implementation. DEVs were reviewed by the SCAMP committee chairperson and by a separate protocol deviation committee; they were characterized as either justifiable (J), possibly justifiable (PJ), or not justifiable (NJ).

RESULTS

We analyzed 415 patients, 484 clinic encounters, and 216 DEVs. Eighty-six (39.8%) of the DEVs were J, 21 (9.7%) were PJ, and 109 (50.4%) were NJ. The percentage of NJ DEVs relative to the number of opportunities for DEV was 4.1%. J and PJ DEVs were mostly due to management of unrelated conditions (11% overall) or special circumstances (22% overall). NJ DEVs primarily involved follow-up intervals (66%) and deleted tests (24%). The reason for deviating from SCAMP recommendations was not given for 31% of DEVs, even though such information was requested.

CONCLUSIONS

The overall low rate of NJ DEV suggests that practitioners generally accept SCAMP recommendations, but improved capture of practitioners' reasons for deviating from those recommendations is needed. This analysis revealed multiple opportunities for improving patient care, suggesting that this process can be useful in both promulgating sound practice and evolving improved approaches to patient management.

Building better guidelines with BRIDGE-Wiz: development and evaluation of a software assistant to promote clarity, transparency, and implementability

OBJECTIVE

To demonstrate the feasibility of capturing the knowledge required to create guideline recommendations in a systematic, structured, manner using a software assistant. Practice guidelines constitute an important modality that can reduce the delivery of inappropriate care and support the introduction of new knowledge into clinical practice. However, many guideline recommendations are vague and underspecified, lack any linkage to supporting evidence or documentation of how they were developed, and prove to be difficult to transform into systems that influence the behavior of care providers.

METHODS

The BRIDGE-Wiz application (Building Recommendations In a Developer's Guideline Editor) uses a wizard approach to address the questions: (1) under what circumstances? (2) who? (3) ought (with what level of obligation?) (4) to do what? (5) to whom? (6) how and why? Controlled natural language was applied to create and populate a template for recommendation statements.

RESULTS

The application was used by five national panels to develop guidelines. In general, panelists agreed that the software helped to formalize a process for authoring guideline recommendations and deemed the application usable and useful.

DISCUSSION

Use of BRIDGE-Wiz promotes clarity of recommendations by limiting verb choices, building active voice recommendations, incorporating decidability and executability checks, and limiting Boolean connectors. It enhances transparency by incorporating systematic appraisal of evidence quality, benefits, and harms. BRIDGE-Wiz promotes implementability by providing a pseudocode rule, suggesting deontic modals, and limiting the use of 'consider'.

CONCLUSION

Users found that BRIDGE-Wiz facilitates the development of clear, transparent, and implementable guideline recommendations.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

Reduction of inappropriate hospital admissions of children with influenza-like illness through the implementation of specific guidelines: a case-controlled study

BACKGROUND

In an attempt to reduce the burden of influenza-like illness (ILI) on health resources, the Italian Ministry of Health released clinical practice guidelines (CPGs) on ILI management that include specific indications for the admission of children to the hospital. The aim of this study was to evaluate whether application of these CPGs reduced the rate of inappropriate hospital admissions.

METHODS

In the first phase, 2 independent observers recorded the number and clinical condition of children presenting with ILI to the emergency department (ED) of a large urban pediatric hospital and the main reasons for hospital admission. The latter were compared with the CPG indications for hospital admission to evaluate appropriateness. One year later (phase 2), we recorded the number of children with ILI admitted to the hospital by pediatricians trained in a 3-hour course on CPGs and by "untrained" control pediatricians.

RESULTS

In phase 1 of the study, 854 children accessed the ED; 318 (37.2%) had ILI. Of the latter, 26.2% were admitted to the hospital, and 33.7% of admissions were inappropriate according to CPG criteria. In phase 2, 16% of the children with ILI were admitted by CPG-trained pediatricians and 25.8% by control pediatricians. The number of inappropriate hospital admissions was higher among control than among CPG-trained pediatricians.

CONCLUSIONS

ILI in children is associated with a high rate of inappropriate hospital admissions. Training of ED pediatricians in the application of a specific CPG may result in a substantial decrease of the admission rate and of inappropriate admissions.

Integrating the Institute of Medicine's six quality aims into pediatric critical care: relevance and applications

The Institute of Medicine's report Crossing the Quality Chasm recommends "six aims for improvement." The aims are safety, effectiveness, equity, timeliness, patient-centeredness, and efficiency. This review focuses on the quality of care information relevant to the Institute of Medicine's six aims to assess their relevance, potential impact, and affect on pediatric critical care practice. It is concluded that if the care for pediatric intensive care patients is to be fundamentally improved, an understanding of the current care environment, the existing evidence base, the opportunities for improvement, and the documentation of the improvements needs to be realized. The Institute of Medicine's six aims provide a useful framework to advance the quality of care in this pediatric subspecialty and perhaps others.

Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies

BACKGROUND

A significant and prolonged decline in the incidence of necrotising enterocolitis (NEC), nearing virtual elimination in some centres, has been observed consistently since implementation of a standardised feeding regimen.

AIM

To systematically review the observational studies reporting incidence of NEC in preterm, low birth weight (LBW) neonates "before" and "after" implementation of a standardised feeding regimen.

METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2002), Medline, Embase, Cinahl, and proceedings of the Pediatric Academic Societies (published in Pediatric Research from 1980) were searched in July and again in October 2003. The reference lists of identified observational studies, and personal files, were searched. No language restriction was applied. Key words were: standardised, enteral, feeding, neonates, necrotising enterocolitis. Authors were contacted for clarification of data.

RESULTS

Six eligible studies (1978-2003) were identified. A significant heterogeneity was noted between the studies indicating the variations in the population characteristics and feeding practices over a period of 25 years. Meta-analysis of the six studies using a random effects model revealed a pooled risk ratio of 0.13 (95% confidence interval 0.03 to 0.50)-that is, introduction of a standardised feeding regimen reduced the incidence of NEC by 87%.

CONCLUSION

Standardised feeding regimens may provide the single most important global tool to prevent/minimise NEC in preterm neonates. Randomised controlled trials are needed.

Managing information

Information management is an essential component in risk management and clinical governance. In neonatology, the areas related to information management are: (1) clinical records; (2) clinical information databases; (3) evidence-based practice; and (4) audit and outcome measures. Record keeping is an integral part of clinical practice and medical records should be an accurate account of clinical details. Clinical information is used for many purposes other than patient-care documentation. Evidence-based medicine is the use of current best evidence to make decisions about the care of individual patients. Benchmarking using illness severity adjustment is a crucial tool for studying variations in outcomes. Neonatal intensive care is well suited to such benchmarking but further development of standardised audit tools - both for interventions and for outcome measures - are required.

Integrating Palliative Care into Disease Management Guidelines

BACKGROUND

Palliative care should not be reserved for those who are close to dying; as a comprehensive approach to minimizing illness-related suffering, it is appropriate for patients with significant illness from the time of diagnosis on.

OBJECTIVE

The American Hospice Foundation Guidelines Committee's initiative aims to provide a practical approach for guideline writers and others to integrate palliative care into disease management and care services whenever it is relevant.

DESIGN

A consensus approach was used to design recommendations for upgrading existing disease management and service guidelines to include palliative care.

RESULTS

A template is described for identifying stages in disease management guidelines when integration of palliative care is appropriate: (1) Introductory sections to disease management guidelines should include prognosis and other disease consequences; (2) Diagnostic sections should include recommendations for conducting a whole patient assessment; (3) Treatment sections should include discernment of patient goals for care, continuous goal reassessment, palliative care interventions to reduce suffering as needed, and treatment decisions should include discussion of the type of expected improvement. Service guidelines should note the role of interdisciplinary team care as well as palliative care consultative or care services; (4) Sections that conclude the care provided to incurable patients should not end without recommendations on grief and bereavement care, and care during the last hours of living.

CONCLUSION

The American Hospice Foundation Guidelines Committee recommends integration of relevant aspects of palliative care in introductory, diagnostic, treatment, and closing sections of management guidelines for all significant illnesses.

A content analysis of forms, guidelines, and other materials documenting end-of-life care in intensive care units

OBJECTIVE

The purpose of this study was to determine the extent to which data entry forms, guidelines, and other materials used for documentation in intensive care units (ICUs) attend to 6 key end-of-life care (EOLC) domains: 1) patient and family-centered decision making, 2) communication, 3) continuity of care, 4) emotional and practical support, 5) symptom management and comfort care, and 6) spiritual support. A second purpose was to determine how these materials might be modified to include more EOLC content and used to trigger clinical behaviors that might improve the quality of EOLC.

PARTICIPANTS

Fifteen adult ICUs-8 medical, 2 surgical, and 4 mixed ICUs from the United States, and 1 mixed ICU in Canada, all affiliated with the Critical Care End-of-Life Peer Workgroup

METHODS

Physician-nurse teams in each ICU received detailed checklists to facilitate and standardize collection of requested documentation materials. Content analysis was performed on the collected documents, aimed at characterizing the types of materials in use and the extent to which EOLC content was incorporated.

MEASUREMENTS AND MAIN RESULTS

The domain of symptom management and comfort care was integrated most consistently on forms and other materials across the 15 ICUs, particularly pain assessment and management. The 5 other EOLC domains of patient and family centered decision-making, communication, emotional and practical support, continuity of care, and spiritual support were not well-represented on documentation. None of the 15 ICUs supplied a comprehensive EOLC policy or EOLC critical pathway that outlined an overall, interdisciplinary, sequenced approach for the care of dying patients and their families. Nursing materials included more cues for attending to EOLC domains and were more consistently preprinted and computerized than materials used by physicians. Computerized forms concerning EOLC were uncommon. Across the 15 ICUs, there were opportunities to make EOLC- related materials more capable of triggering and documenting specific EOLC clinical behaviors.

CONCLUSIONS

Inclusion of EOLC items on ICU formatted data entry forms and other materials capable of triggering and documenting clinician behaviors is limited, particularly for physicians. Standardized scales, protocols, and guidelines exist for many of the EOLC domains and should be evaluated for possible use in ICUs. Whether such materials can improve EOLC has yet to be determined.

Early NICU discharge of very low birth weight infants: a critical review and analysis

Early neonatal intensive care unit (NICU) discharge has been advocated for selected preterm infants to reduce both the adverse environment of prolonged hospital stay and to encourage earlier parental involvement by empowering parents to contribute to the ongoing care of their infant, and thereby reducing costs of care. Randomized trials and descriptive experiences of early discharge programs are critically reviewed over the last 30 years, and the key elements necessary for successful early discharge are reviewed and defined. Early discharge is clearly achievable for a large number of infants. Variations in neonatal care practices are reviewed since these variations have been documented to influence NICU stay. Management of apnea of prematurity and feeding practices is documented to significantly influence NICU length of stay, as is timing of discharge based on institutional factors. Developmentally centered care, use of nutritional supplements pre- and postdischarge, hearing screening programs, evaluation for retinopathy of prematurity, evaluation for apnea and bradycardia events, and cardiopulmonary stability while in a car seat all influence timing of discharge. Programs of early hospital discharge with home nursing and neonatologist support have been successful in lowering the length of NICU stay. However, trends in length of stay in NICUs indicate that for infants >750 g at birth over the last decade there have been insignificant reductions in length of hospital stay. Thus, because of the increase in the percentage of low birth weight infants in the US, there remain opportunities to improve on variations in care that will be translated to fewer NICU days in hospitals for selected infants. Several professional guidelines are summarized, and standards of care as related to discharge of premature infants are reviewed.

[Neonatal resuscitation in the delivery room: educational process and evaluation]

Based upon a three necessities basis: public health, biological and medico-legal, this article presents the state of the art about teaching neonatal resuscitation in the delivery room. The educational process is present worldwide; main experiences are described. Evaluation of these actions varies in the literature. We analyze the evaluation of the process of the trained professionals, their satisfaction, the changes in their practices, their theoretical and practical levels, and the impact on newborns' health. We propose a few measures to make official this kind of teaching in France, with a certificate for instructors and trained professionals.

Pediatrician-parent-child communication: problem-related or not?

Pediatricians are generally confronted with a variety of health problems. Each of these problems may benefit from another pattern of healthcare communication. It is unknown whether the communication process during pediatric visits actually differs by the nature of the child's problem. This study first examined whether three formerly identified communication patterns could be distinguished within real-life pediatric outpatient encounters (N=846). Then, communication patterns during encounters with children with respiratory (n=269) or behavioral problems (n=77) were compared. Videotaped visits were observed using the Roter Interaction Analysis System. Two-level multivariate logistic regression analysis examined what factors contributed to the communication patterns. A biopsychosocial communication pattern was observed in 45%, a psychosocial in 15% and a biomedical pattern in 40% of the visits. Child's age and pediatrician's experience were related to the communication pattern. Different patterns did indeed prevail in respiratory and behavioral problems. As less experienced pediatricians attend to psychosocial issues less, they may have to be specifically encouraged to do so.

Practice parameters in pediatric allergy

The primary role of practice parameter/guidelines and other boundaries developed for the field of medicine is to improve the quality of patient care. Practice parameters/guidelines are also important for education, interaction with managed care and third-party payers, establishing appropriate variables for outcome assessment, reducing inappropriate variation in clinical practice, and resolving medical-legal issues. National specialty organizations, the American Medical Association, and government agencies have been actively involved in developing and promoting practice parameters. These documents provide a framework within which pediatricians can provide the best quality of care for their patients.

Does a paediatric after-hours clinic use evidence-based guidelines in the management of acute otitis media?

OBJECTIVE

To determine whether a paediatric after-hours clinic uses evidence-based management in the treatment of acute otitis media, and compare this management with that provided in a paediatric emergency department and a general hospital emergency department.

METHODS

A retrospective chart review of 573 patients (aged six months to five years) with a discharge diagnosis of acute otitis media was conducted in three after-hours settings: a paediatric after-hours clinic, a tertiary paediatric hospital emergency department and a secondary general hospital emergency department. The patients' age, weight, sex and allergy to antibiotics were recorded as baseline characteristics. The physicians' antibiotic choice, dose and duration, and the use of investigations were recorded as outcome variables.

RESULTS

Amoxicillin was prescribed to 68% of patients at both the paediatric after-hours clinic and the paediatric hospital emergency department, compared with 53% of patients at the general hospital emergency department (P<0.01). The mean dose of amoxicillin prescribed at the paediatric after-hours clinic and the paediatric hospital emergency department were similar (43.4±9.7 mg/kg per day and 42.4±14.3 mg/kg per day, respectively) and higher than that prescribed at the general hospital emergency department (38.6±8.8 mg/kg per day, P<0.01). The paediatric after-hours clinic used investigations less often than did emergency departments (0.5% of cases compared with 9% and 20%, P<0.01).

CONCLUSION

The paediatric after-hours clinic provided a high level of adherence to a clinical practice guideline and had a low utilization of resource intensive investigations.

Does a clinical pathway improve the quality of care for sickle cell anemia?

BACKGROUND

Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.

RESULTS

Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.

DISCUSSION

Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.

Factors influencing hospital implementation of acute pain management practice guidelines

STUDY OBJECTIVE

To identify factors that may influence the implementation of acute pain management guidelines in hospital settings.

DESIGN

Two questionnaire surveys.

SETTING

Healthcare Association of New York State, Albany, NY.

MEASUREMENT

The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage.

MAIN RESULTS

According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements.

CONCLUSIONS

Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Early high-frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation in very low birth weight infants: a pilot study of two ventilation protocols

OBJECTIVE

To evaluate the feasibility of conducting a prospective, randomized trial comparing early high-frequency oscillatory ventilation (HFOV) to synchronized intermittent mandatory ventilation (SIMV) in very low birth weight (VLBW) premature infants. This pilot study evaluated two ventilator management protocols to determine how well they could be implemented in a multicenter clinical trial. Although this pilot study was not powered to detect differences in outcome, we also collected outcome data.

DESIGN

Prospective, multicenter, randomized pilot study.

SETTING

Seven tertiary-level intensive care nurseries with previous experience with both HFOV and flow-triggered SIMV.

PATIENTS

Fifty infants weighing 501 to 1200 g, less than 4 hours of age, who had received one dose of surfactant and required ventilation with mean airway pressure > or =6 cm H2O and F(I)O2 > or =0.25, and had an anticipated duration of ventilation greater than 24 hours.

INTERVENTIONS

Patients were stratified by birth weight and prenatal steroid status, then randomized to either HFOV or SIMV with tidal volume monitoring. Ventilator management for patients in both study arms was strictly governed by protocols that included optimizing lung inflation and blood gases, weaning strategies, and extubation criteria.

MEASUREMENTS

Data were collected using the tools planned for the larger collaborative study. Protocol compliance was closely monitored, with successive changes in the protocol made as necessary to improve clarity and increase compliance. The incidence of major neonatal adverse outcomes was recorded.

MAIN RESULTS

Data are presented for 24 HFOV and 24 SIMV infants (two infants, twins, were withdrawn from the study at parent's request). Nineteen of the 24 HFOV infants and 20 of the 24 SIMV infants survived to 36 weeks corrected age. Age at final extubation for survivors was 16+/-16 (mean+/-SD) days for HFOV infants and 24+/-24 days for SIMV infants. At 36 weeks corrected age, 14 of the 19 HFOV survivors were extubated and in room air, whereas 5 required supplemental oxygen. In comparison, 6 of the 20 SIMV survivors were extubated and in room air, whereas 14 required supplemental oxygen. Grade III/IV IVH and/or periventricular leukomalacia occurred in 2 HFOV and 2 SIMV patients. Overall compliance with the ventilator protocols was 82% for the SIMV protocol, and 88% for the HFOV protocol.

CONCLUSIONS

The preliminary outcome data supports conducting the large randomized trial, which began in July of 1998. The protocols for the ventilator management of VLBW infants, both with HFOV and with SIMV were easily implemented and consistently followed, and are presented here.

A report card on quality improvement for children's health care

OBJECTIVE

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research.

METHODS

To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program.

RESULTS

We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults.

CONCLUSIONS

Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

[Office-based pediatricians' knowledge and adherence to a consensus statement on acute rhinopharyngitis in the child]

AIM

To assess the impact on community-based pediatricians of the conclusions of the 10th Conférence de Consensus en Thérapeutique Anti-Infectieuse (CCTAI) on the antibiotic treatment in acute nasopharyngitis (ANP).

METHODS

Fifty-six pediatricians took part in the study. Over a period of 15 days in October 1998, all the children (n = 997) presenting an ANP were prospectively included. The prescription of an antibiotic treatment as well as the clinical criteria authorizing it, according to the conclusions of the 10th CCTAI, were recorded. The participants were not told the purpose of the study.

RESULT

Sixty percent of the pediatricians questioned were familiar with the 10th CCTAI. Forty-five percent said they complied with it, but only 7% stated it had changed their day-to-day clinical practice. Based on the conclusions of the 10th CCTAI, an antibiotic treatment would have been discussed for 38% of the children. Twenty-four percent of them were given one. For 54% of the children that were given an antibiotic, such treatment was disapproved by the 10th CCTAI. No significant association has been established between familiarity with the 10th CCTAI and the following criteria: gender, age, hospital activity, years of practice, medical journals read, and belief in the existence of a license for one or more antibiotics for ANP in children. However, this last criterion was significantly (P = 0.03) associated with an increase in the percentage of antibiotics prescribed: 29% vs 16%.

DISCUSSION AND CONCLUSION

The 10th CCTAI has had a moderate impact on the day-to-day practice of the pediatricians who took part in our study. Several explanations are discussed. The authors emphasize the virtual lack of indications of antibiotics in ANP.

A guideline implementation system using handheld computers for office management of asthma: effects on adherence and patient outcomes

OBJECTIVE

To evaluate effects on the process and outcomes of care brought about by use of a handheld, computer-based system that implements the American Academy of Pediatrics guideline on office management of asthma exacerbations.

DESIGN

A before-after trial with randomly selected, office-based Connecticut pediatricians. In both the control and intervention phases, physicians collected data from 10 patient encounters for acute asthma exacerbations. During the intervention phase, the computer provided for structured encounter documentation and offered recommendations based on the guideline of the American Academy of Pediatrics. Patients were contacted by telephone 7 to 14 days after the visit to assess outcomes.

RESULTS

Nine study-physicians enrolled 91 patients in the control phase and 74 in the intervention phase. Follow-up information was available for 93% of encounters. Use of the intervention was associated with increased mean frequency/visit of: 1) measurements of peak expiratory flow rate (2.18 vs 1.57) and oxygen saturation (1.12 vs.42), and 2) administration of nebulized beta2-agonists (1.25 vs.71). Visits in the intervention phase lasted longer and fees were higher ($145.61 vs $103.11). There were no significant differences in immediate disposition or subsequent emergency department visits, hospitalizations, missed school, or caretaker's missed work during the 7 days post visit.

CONCLUSION

Use of handheld computers that provide guideline-based decision support was associated with increased physician adherence to guideline recommendations; however, visits were prolonged, fees were higher, and no improvement could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline implementers (and users) should be cautious about putting unvalidated recommendations into practice.

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

Pediatric practice guidelines: implications for nurse practitioners

Practice guidelines are promoted as an important means of achieving high-quality, cost-effective health care. Nurse practitioners must understand what practice guidelines are and how they are developed and be willing to put them into practice. This discussion begins with a description of practice guidelines specific to pediatrics. The terminology used in reference to these "clinical tools" are differentiated and their historic and contemporary influences are summarized. The complexity of guideline development and attributes of a quality practice guideline are described. Finally, the pivotal roles nurse practitioners can play in putting guidelines into practice are suggested.

Developing better critical paths in healthcare: combining 'best practice' and the quantitative approach

Critical paths are tools to manage healthcare delivery and ensure favorable patient outcomes. Unfortunately, many of these paths are not evaluated or revised after their initial development. One potential problem faced by nursing managers is that critical paths may lose relevance in a rapidly changing healthcare environment. The authors suggest one strategy to strengthen existing critical paths in a way that is responsive to these changes.

Principles of disease management in neonatology

This article emphasizes the emerging facets of disease-management practice that impact directly on establishing a measured care system that can produce the information needed to establish a continuous quality improvement program. The areas discussed are risk assessment, clinical management guidelines and carepaths, and the measurement of system output known as clinical outcomes. The remainder of the article details the aspects of risk assessment, guideline function, and outcome assessment, critical in a disease-managed measured care system.