Implementing nursing best practice guidelines: impact on patient referrals.

BMC Nurs. 2007 Jun 28;6(1):4

Authors: Edwards N, Davies B, Ploeg J, Virani T, Skelly J

ABSTRACT: BACKGROUND: Although referring patients to community services is important for optimum continuity of care, referrals between hospital and community sectors are often problematic. Nurses are well positioned to inform patients about referral resources. The objective of this study is to describe the impact of implementing six nursing best practice guidelines (BPGs) on nurses’ familiarity with patient referral resources and referral practices. METHODS: A prospective before and after design was used. For each BPG topic, referral resources were identified. Information about these resources was presented at education sessions for nurses. Pre- and post-questionnaires were completed by a random sample of 257 nurses at 7 hospitals, 2 home visiting nursing services and 1 public health unit. Average response rates for pre- and post-implementation questionnaires were 71% and 54.2%, respectively. Chart audits were completed for three BPGs (n=421 pre- and 332 post-implementation). Post-hospital discharge patient interviews were conducted for four BPGs (n=152 pre- and 124 post-implementation). RESULTS: There were statistically significant increases in nurses’ familiarity with resources for all BPGs, and self-reported referrals to specific services for three guidelines. Higher rates of referrals were observed for services that were part of the organization where the nurses worked. There was almost a complete lack of referrals to Internet sources. No significant differences between pre- and post-implementation referrals rates were observed in the chart documentation or in patients’ reports of referrals. CONCLUSIONS: Implementing nursing BPGs, which included recommendations on patient referrals produced mixed results. Nurses’ familiarity with referral resources does not necessarily change their referral practices. Nurses can play a vital role in initiating and supporting appropriate patient referrals. BPGs should include specific recommendations on effective referral processes and this information should be tailored to the community setting where implementation is taking place.

PMID: 17598917 [PubMed - as supplied by publisher]

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The SAGE Guideline Model: Achievements and Overview.

J Am Med Inform Assoc. 2007 Jun 28;

Authors: Tu SW, Campbell JR, Glasgow J, Nyman MA, McClure R, McClay J, Parker C, Hrabak KM, Berg D, Weida T, Mansfield JG, Musen MA, Abarbanel RM

The SAGE (Standards-Based Active Guideline Environment) project was formed to create a methodology and infrastructure required to demonstrate integration of decision-support technology for guideline-based care in commercial clinical information systems. This paper describes the development and innovative features of the SAGE Guideline Model and reports our experience encoding four guidelines. Innovations include methods for integrating guideline-based decision support with clinical workflow and employment of enterprise order sets. Using SAGE, a clinician informatician can encode computable guideline content as recommendation sets using only standard terminologies and standards-based patient information models. The SAGE Model supports encoding large portions of guideline knowledge as re-usable declarative evidence statements and supports querying external knowledge sources.

PMID: 17600098 [PubMed - as supplied by publisher]

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Learning curve analysis of thoracic endovascular aortic repair in relation to credentialing guidelines.

J Vasc Surg. 2007 Jun 26;

Authors: Forbes TL, Chu MW, Lawlor DK, Derose G, Harris KA

OBJECTIVE: Recently, practice guideline documents have recommended the completion of different levels of interventional experience and 5 or 10 thoracic endovascular aortic cases prior to surgeon credentialing. This study’s purpose was to determine whether these requirements are valid by reviewing three surgeons’ learning curves with thoracic aortic endovascular repairs. METHODS: Between 1998 and 2006, 67 patients underwent emergent or elective endovascular repair of thoracic aortic pathologies by one of three vascular surgeons with extensive experience with catheter manipulation and abdominal aortic endografts. Following standard retrospective review, each surgeon’s learning curve was analyzed using the cumulative sum failure method with a target success rate of 95% derived from the literature. The main outcome variable was primary technical success. RESULTS: These 67 patients presented with several pathologies including elective (n = 31) and ruptured (n = 11) thoracic aortic aneurysms, acute dissections or aortic ulcers (n = 10), and acute blunt thoracic aortic trauma (n = 15). The mean age was 65 (range: 20 to 90) and the early (30 day) mortality rate was 19.4% in urgent cases (n = 36) and 0% in elective cases (n = 31). Paraplegia occurred in two patients (3%). Primary technical success was achieved in 62 cases (92.5%) and did not differ between surgeons (92.6%, 91.3%, 94.1%, respectively; P = .9). Each surgeon’s cases were plotted sequentially and the resulting learning curves were similar. Although acceptable outcomes were obtained throughout the study period, improved results, compared with the target success rate, were not achieved until each surgeon treated 5 to 10 patients. CONCLUSION: This study supports the case volume requirements of the Society for Vascular Surgery credentialing guidelines, which also requires extensive catheter and guidewire experience. With this background in catheter manipulation and endovascular abdominal aortic repair, surgeons can achieve optimal outcomes with thoracic aortic lesions following 5 to 10 cases.

PMID: 17600665 [PubMed - as supplied by publisher]

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Endometrial safety assessment of a specific and standardized soy extract according to international guidelines.

Menopause. 2007 Jun 28;

Authors: Palacios S, Pornel B, Bergeron C, Chantre P, Nogales F, Aubert L, Vazquez F, Eden J, Mares P

OBJECTIVE:: To assess the effects of an oral soy isoflavone extract (Phytosoya) on endometrium (evaluated by biopsy and ultrasonography) in postmenopausal women treated for 12 months. DESIGN:: A total of 395 postmenopausal women were included in this international prospective, open-label study. The women were treated for 12 months with a specific standardized soy isoflavone extract (total of 70 mg/d). Endometrial biopsy and transvaginal ultrasonography were performed before and after 12 months of treatment according to European guidelines. RESULTS:: A total of 301 assessable biopsy specimens were obtained from women treated for 12 months; the results were 99.67% atrophic/inactive endometrium and 0.33% proliferative endometrium. No case of hyperplasia or carcinoma was diagnosed, demonstrating the endometrial safety of this extract (point estimate: 0.0; upper limit of 95% CI: 0.012). Endometrial thickness did not show any increase after 12 months of treatment (2.2 mm at inclusion and 2.12 mm at the end of the study). Only eight women reported some kind of bleeding as an adverse event during the study. CONCLUSIONS:: These results of endometrial biopsy and endometrial thickness suggest that daily administration of 70 mg of a specific and standardized isoflavone extract for 12 months does not stimulate the endometrium.

PMID: 17603393 [PubMed - as supplied by publisher]

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Developing search strategies for clinical practice guidelines in SUMSearch and Google Scholar and assessing their retrieval performance.

BMC Med Res Methodol. 2007 Jun 30;7(1):28

Authors: Haase A, Follmann M, Skipka G, Kirchner H

ABSTRACT: BACKGROUND: Information overload, increasing time constraints, and inappropriate search strategies complicate the detection of clinical practice guidelines (CPGs). The aim of this study was to provide clinicians with recommendations for search strategies to efficiently identify relevant CPGs in SUMSearch and Google Scholar. METHODS: We compared the retrieval efficiency (retrieval performance) of search strategies to identify CPGs in SUMSearch and Google Scholar. For this purpose, a two-term GLAD (GuideLine And Disease) strategy was developed, combining a defined CPG term with a specific disease term (MeSH term). We used three different CPG terms and nine MeSH terms for nine selected diseases to identify the most efficient GLAD strategy for each search engine. The retrievals for the nine diseases were pooled. To compare GLAD strategies, we used a manual review of all retrievals as a reference standard. The CPGs detected had to fulfil predefined criteria, e.g., the inclusion of therapeutic recommendations. Retrieval performance was evaluated by calculating so-called diagnostic parameters (sensitivity, specificity, and Number Needed to Read [NNR]) for search strategies. RESULTS: The search yielded a total of 2830 retrievals; 987 (34.9%) in Google Scholar and 1843 (65.1%) in SUMSearch. Altogether, we found 119 unique and relevant guidelines for nine diseases (reference standard). Overall, the GLAD strategies showed a better retrieval performance in SUMSearch than in Google Scholar. The performance pattern between search engines was similar: search strategies including the term guideline yielded the highest sensitivity (SUMSearch: 81.5%; Google Scholar: 31.9%), and search strategies including the term practice guideline yielded the highest specificity (SUMSearch: 89.5%; Google Scholar: 95.7%), and the lowest NNR (SUMSearch: 7.0; Google Scholar: 9.3). CONCLUSIONS: SUMSearch is a useful tool to swiftly gain an overview of available CPGs. Its retrieval performance is superior to that of Google Scholar, where a search is more time consuming, as substantially more retrievals have to be reviewed to detect one relevant CPG. In both search engines, the CPG term guideline should be used to obtain a comprehensive overview of CPGs, and the term practice guideline should be used if a less time consuming approach for the detection of CPGs is desired.

PMID: 17603909 [PubMed - as supplied by publisher]

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[Diagnosis and treatment of postmenopausal osteoporosis and osteoporosis in men : German Guidelines Update 2006.]

Orthopade. 2007 Jul;36(7):683-692

Authors: Kurth AA, Pfeilschifter J

The treatment of osteoporosis and prevention of osteoporotic fractures consists of both non-drug and drug therapy. Components of non-drug therapy include the improvement of muscle strength and coordination, treatment of modifiable causes of falls, a diet rich in calcium and sufficient in calories, an adequate supply of Vitamin D and an individual assessment of drugs known to increase falls or osteoporosis. The updated DVO diagnostic and treatment guidelines for osteoporosis recommends a 30% 10-year probability for vertebral and hip fractures as an intervention threshold for drug treatment. Using epidemiological fracture data from central Europe, the guidelines provides an assessment of absolute 10-year fracture risk based on a combination of age, gender, prevalent fragility fractures, spine and total hip dual-energy x-ray absorptiometry (DXA) measurements and several other clinical risk factors.

PMID: 17605128 [PubMed - as supplied by publisher]

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Lipid management in cardiovascular disease prevention guidelines: Strategies and tactics for implementation.

Atherosclerosis. 2007 Jun 30;

Authors: Erhardt LR, Leiter LA, Richard Hobbs FD

Despite the widespread dissemination of clinical practice guidelines on the prevention and treatment of cardiovascular disease (CVD), CVD causes one third of deaths worldwide and almost half of all deaths in the developed world. It is therefore likely that, although some aspects of CVD management have improved, there is still a significant shortfall between what is known about CVD prevention and what is put into action. Twenty-one experts in the field of CVD from around the world attended a focus panel meeting in Marlow-on-Thames, UK (see acknowledgements for a list of meeting participants). These experts were invited to discuss practical strategies and tactics for overcoming barriers to the implementation of guidelines on CVD prevention, and lipid management in particular. This article reviews and updates the key topics presented during the course of the meeting, captures the essence of the group discussions, and summarizes the meeting outcomes. The participants concluded that initial efforts to implement CVD prevention guidelines more effectively are best directed at high-risk patients who have already been identified. Once current patients achieve their targets, more attention can be paid to finding untreated patients at risk. Recommendations from the expert panel included:

PMID: 17606265 [PubMed - as supplied by publisher]

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Bufale Spotting, part 4: Assessing a guideline.

J R Soc Med. 2007 Jul;100(7):325

Authors: Jefferson T, Zarra L

PMID: 17606753 [PubMed - in process]

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The natural history and treatment of chronic hepatitis B: a critical evaluation of standard treatment criteria and end points.

Ann Intern Med. 2007 Jul 3;147(1):58-61

Authors: Lai CL, Yuen MF

The definite indications for the treatment of chronic hepatitis B are serum hepatitis B virus (HBV) DNA levels greater than 10(5) copies/mL and alanine aminotransferase (ALT) levels more than 2 times the upper limit of normal. If cirrhosis is present, an HBV DNA level greater than 10(5) copies/mL is the sole criterion for treatment. Treatment end points include hepatitis B e antigen (HBeAg) seroconversion for HBeAg-positive patients, reduction of HBV DNA levels to less than 10(5) copies/mL, and normalization of ALT values. These guidelines may apply to patients who acquire the hepatitis B infection during adolescence or adulthood but are less suitable for most hepatitis B carriers, who are infected in early life. Cirrhosis complications, including hepatocellular carcinoma, often occur in this latter group despite HBeAg seroconversion, HBV DNA levels less than 10(4) copies/mL, or ALT levels between 0.5 and 2 times the upper limit of normal. Therefore, HBeAg seroconversion may not be an adequate end point for these patients; the ideal treatment end points are permanent suppression of HBV DNA to levels undetectable by polymerase chain reaction and reduction of ALT levels to less than 0.5 times the upper limit of normal.

PMID: 17606962 [PubMed - indexed for MEDLINE]

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[Absolute Risk for Fracture and WHO Guideline.WHO model for assessing absolute risk of fracture.]

Clin Calcium. 2007 Jul;17(7):1015-21

Authors: Iki M

Goal for management of osteoporosis is prevention of fractures, although the diagnosis of osteoporosis is made according to bone mineral density (BMD) which plays a great role in monitoring the effectiveness of treatment. However, there are many countries and regions where BMD measurement is not available in primary health care. Even if it is available, BMD shows limited validity in predicting fracture risk. A research group of the World Health Organization (WHO) has developed absolute risk assessment models for fracture incorporating several clinical risk factors with and without BMD. The present paper described the outline of these models and addressed several issues when applying these models to the primary medical care and preventive practice in Japan.

PMID: 17607067 [PubMed - in process]

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