Related ArticlesEffectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis–a single-centre experience.

Nephrol Dial Transplant. 2006 Nov 24;

Authors: Lee W, Campoy S, Smits G, Vu Tran Z, Chonchol M

BACKGROUND: Limited data exist about the effects of chronic kidney disease (CKD) clinics on quality-of-care indicators in patients before initiation of dialysis. METHODS: A single-centre retrospective chart review study was conducted on all patients who initiated dialysis at the Veterans Affairs Denver Healthcare System between 2000 and 2005. Patients initiating dialysis were evaluated at the start of dialysis and 12 months after dialysis initiation, as a function of care provided by nephrologists in training (renal-hypertension clinic) vs a trained renal nurse practitioner (CKD clinic). RESULTS: Data were available for 77 patients followed in the CKD clinic and 36 in the renal-hypertension clinic. There were no major demographic differences between the cohorts at the time of clinic referral. The length of follow-up before dialysis did not differ significantly between the cohorts (10.7+/-9.8 months for the patients in the CKD clinic cohort and 13.6+/-16.0 months for the patients in the renal-hypertension clinic cohort, P=0.3299). At the initiation of dialysis, patients followed in the CKD clinic had higher haemoglobin (11.6+/-1.5 vs 10.8+/-1.7 g/dl, P=0.0239) and serum albumin (3.4+/-0.5 vs 3.0+/-0.7 g/dl, P=0.0020) concentrations. More of the CKD clinic patients had a functioning permanent vascular access (P

PMID: 17127695 [PubMed - as supplied by publisher]

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Related ArticlesAdherence of Irish general practitioners to European guidelines for acute low back pain: A prospective pilot study.

Eur J Pain. 2006 Nov 22;

Authors: Fullen BM, Maher T, Bury G, Tynan A, Daly LE, Hurley DA

There are no national low back pain (LBP) clinical guidelines in Ireland, and neither the level of adherence of General Practitioners (GPs) to the European guidelines, nor the cost of LBP to the patient and the state, have been investigated. A prospective pilot study was conducted on 54 consenting patients (18M, 36F: mean age (SD): 40.5 (14.3) years) with a new episode of acute LBP (

PMID: 17126046 [PubMed - as supplied by publisher]

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Related ArticlesNurses’ knowledge and application of evidence-based guidelines for preventing ventilator-associated pneumonia.

Minerva Anestesiol. 2006 Nov 20;

Authors: Biancofiore G, Barsotti E, Catalani V, Landi A, Bindi L, Urbani L, Desimone P, Stefanini A, Sansevero A, Filipponi F

AIM: The aim of the study was to evaluate the nurses’ knowledge and application of evidence-based guidelines that foresee non-pharmacological actions for preventing ventilation-associated pneumonia (VAP) by highlighting the causes that may make their use difficult. METHODS: Experimental design: descriptive study. Setting and participants: 106 nurses working in the ICUs of a major Italian hospital of national importance. Intervention: administration of a questionnaire listing 21 non-pharmacological strategies considered the most useful in the literature. RESULTS: Eighty-four nurses responded to the questionnaire. Only 19 (22.6%) declared that their knowledge of VAP and the strategies used to prevent it was satisfactory, whereas 46 (54.8%) declared that they were poorly informed; 68 nurses (80.9%) said that they applied at least one of the strategies, and 15 (17.9%) that they applied none. The reasons given for not applying the strategies were: method not foreseen in Department protocols (31.5%), a lack of the necessary resources (14.3%), disagreement with the method (3.2%), high costs (2.6%), the possibility of causing discomfort (1%) or side effects to the patient (0.6%). CONCLUSIONS: In our experience, VAP preventive strategies are widely applied by nurses, but not in a responsible and informed manner. It is important to ensure that nurses receive continuous training and are involved in drawing up and updating Departmental protocols and guidelines for care and behaviour.

PMID: 17115016 [PubMed - as supplied by publisher]

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Related ArticlesEstimation of the optimal brachytherapy utilization rate in the treatment of carcinoma of the uterine cervix: review of clinical practice guidelines and primary evidence.

Cancer. 2006 Nov 15;

Authors: Thompson S, Delaney G, Gabriel GS, Jacob S, Das P, Barton M

BACKGROUND.: Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU). METHODS.: Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed. RESULTS.: The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillence, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU). CONCLUSIONS.: BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors’ model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation. Cancer 2006. (c) 2006 American Cancer Society.

PMID: 17109449 [PubMed - as supplied by publisher]

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Related ArticlesMild therapeutic hypothermia after cardiac arrest-A nationwide survey on the implementation of the ILCOR guidelines in German intensive care units.

Resuscitation. 2006 Nov 9;

Authors: Wolfrum S, Radke PW, Pischon T, Willich SN, Schunkert H, Kurowski V

AIM: To investigate the implementation of mild therapeutic hypothermia (MTH) after cardiac arrest into clinical practice. METHODS AND RESULTS: A structured evaluation questionnaire was sent to all German hospitals registered to have ICUs; 58% completed the survey. A total of 93 ICUs (24%) reported to use MTH. Of those, 93% started MTH in patients after out-of-hospital resuscitation with observed ventricular fibrillation and 72% when other initial rhythms were observed. Only a minority of ICUs initiate MTH in patients after cardiac arrest with cardiogenic shock (28%), whereas 48% regarded cardiogenic shock as a contra-indication for MTH. On average, target temperature was 33.1+/-0.6 degrees C and duration of cooling 22.9+/-4.9h. Many centres used economically priced cold packs (82%) and cold infusions (80%) for cooling. The majority of the ICUs considered infection, hypotension and bleeding as relevant complications of hypothermia which was of therapeutic relevance in less than 25% of the cases. CONCLUSIONS: MTH is underused in German ICUs. Centres which use MTH widely follow the recommendations of ILCOR with respect to the indication and timing of cooling. In hospitals that use MTH the technique is considered to be safe and inexpensive. More efforts are needed to promote this therapeutic option and hypothermia since MTH has now been included into European advanced cardiovascular life support protocols.

PMID: 17097795 [PubMed - as supplied by publisher]

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Related ArticlesFailure to implement hospital antimicrobial prescribing guidelines: experience in another UK academic centre.

J Antimicrob Chemother. 2006 Nov 9;

Authors: Mahungu J, Fajemisin O, Bowler IC

PMID: 17095525 [PubMed - as supplied by publisher]

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Related ArticlesA Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home-Acquired Pneumonia in a State Veterans Home.

J Am Geriatr Soc. 2006 Nov;54(11):1694-1700

Authors: Hutt E, Ruscin JM, Corbett K, Radcliff TA, Kramer AM, Williams EM, Liebrecht D, Klenke W, Hartmann S

OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN: Pre-posttest with untreated control group. SETTING: Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS: Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION: Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS: Subjects’ SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS: At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION: Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.

PMID: 17087696 [PubMed - as supplied by publisher]

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Related ArticlesImplementing referral guidelines: Lessons from a negative outcome cluster randomised factorial trial in general practice.

BMC Fam Pract. 2006 Nov 2;7(1):65

Authors: Jiwa M, Skinner P, Coker AO, Shaw L, Campbell M, Thompson J

ABSTRACT: BACKGROUND: Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion. However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral. METHODS: A cluster randomised factorial trial. 44 general practices in North Trent, UK. Practices were offered either an electronic interactive referral pro forma, an educational outreach visit by a local colorectal surgeon, both or neither. The main outcome measure was the proportion of cases with severe diverticular disease, cancer or precancerous lesions and inflammatory bowel disease in those referred by each group. A secondary outcome was a referral letter quality score. Semi-structured interviews were conducted to identify key themes relating to the use of the software RESULTS: From 150 invitations, 44 practices were recruited with a total list size of 265,707. There were 716 consecutive referrals recorded over a six-month period, for which a diagnosis was available for 514. In the combined software arms 14% (37/261) had significant pathology, compared with 19% (49/253) in the non-software arms, relative risk 0.73 (95% CI: 0.46 to 1.15). In the combined educational outreach arms 15% (38/258) had significant pathology compared with 19% (48/256) in the non-educational arms, relative risk 0.79 (95% CI: 0.50 to 1.24). Pro forma practices documented better assessment of patients at referral. CONCLUSIONS: There was a lack of evidence that either intervention increased the proportion of patients with organic pathology among those referred. The interactive software did improve the amount of information relayed in referral letters although we were unable to confirm if this made a significant difference to patients or their health care providers. The potential value of either intervention may have been diminished by their limited uptake within the context of a cluster randomised clinical trial. A number of lessons were learned in this trial of novel innovations. Trial registration: Current Controlled Trials ISRCTN10184669.

PMID: 17078894 [PubMed - as supplied by publisher]

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Related ArticlesEvidence-Based Strategies for Implementing Guidelines in Obstetrics: A Systematic Review.

Obstet Gynecol. 2006 Nov;108(5):1234-1245

Authors: Chaillet N, Dubé E, Dugas M, Audibert F, Tourigny C, Fraser WD, Dumont A

OBJECTIVE: To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics. DATA SOURCES: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts’ suggestions. METHODS OF STUDY SELECTION: Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards. TABULATION, INTEGRATION, AND RESULTS: Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions. CONCLUSION: Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

PMID: 17077251 [PubMed - as supplied by publisher]

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Related ArticlesInitiating Highly Active Antiretroviral Therapy in Human Immunodeficiency Virus Type 1-Infected Children in Europe and the United States: Comparing Clinical Practice to Guidelines and Literature Evidence.

Pediatr Infect Dis J. 2006 Nov;25(11):987-994

Authors: Verweel G, Saavedra-Lozano J, van Rossum AM, Ramilo O, de Groot R

Several guidelines are available to guide the initiation of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected children. The recommendations in these guidelines show significant variability. Because there is no well-established evidence on when to start HAART, it is left to the discretion of the pediatrician which guidelines to follow. We conducted a survey concerning the indications for starting antiretroviral therapy among pediatricians involved in the treatment of HIV-infected patients in Europe and the United States. We compared the results of this survey with the guidelines available at the time, the recently adapted guidelines and literature evidence. Our results indicate that in clinical practice HAART was initiated at higher viral loads and lower CD4 counts than recommended by the guidelines. American guidelines recommended and still recommend more aggressive treatment than the European guidelines, and this is reflected in clinical practice. Until recently all guidelines were based on long term risk analyses of progression to acquired immunodeficiency syndrome (AIDS) and death performed in cohort data. A recent short term risk analysis makes it possible to calculate the 6 or 12-month risk for progression to AIDS or death for an individual child. Because viral load and CD4 count are typically measured every 3 months, one can argue that it is clinically more relevant to base the decision of when to start HAART on the short term probability of disease progression. Guidelines in Europe are now based on this type of analysis. The American guidelines only adopted the thresholds for CD4 and viral load. The short term risk analysis also shows that the risk for developing AIDS varies markedly with age. This should be reflected in all guidelines. Determining the acceptable risk of disease progression is difficult and influenced by patient-, doctor- and culture-related factors. The controversy over whether or not to treat asymptomatic infants is unresolved as well. All infants have a very high risk of disease progression regardless of their viral load or CD4 count, but lifelong treatment with a potential for significant toxicities and risk of developing resistance is also not an appealing option. We recommend an attempt to achieve a consensus among the different working groups to reduce the number of different guidelines, which should be based on the literature evidence. Because all risk analyses are based on information from the pre-HAART era, a head-to-head trial comparing early versus deferred HAART would be useful. This may be difficult to accomplish. The first step could be an analysis of retrospective data from collaborative cohort data.

PMID: 17072119 [PubMed - as supplied by publisher]

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