Guideline implementation research: exploring the gap between evidence and practice in the CRUSADE Quality Improvement Initiative.

Acad Emerg Med. 2007 Nov;14(11):949-54

Authors: Blomkalns AL, Roe MT, Peterson ED, Ohman EM, Fraulo ES, Gibler WB

Translating research results into routine clinical practice remains difficult. Guidelines, such as the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and non-ST-segment elevation myocardial infarction, have been developed to provide a streamlined, evidence-based approach to patient care that is of high quality and is reproducible. The Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation (CRUSADE) Quality Improvement Initiative was developed as a registry for non-ST-segment elevation acute coronary syndromes to track the use of guideline-based acute and discharge treatments for hospitalized patients, as well as outcomes associated with the use of these treatments. Care for more than 200,000 patients at more than 400 high-volume acute care hospitals in the United States was tracked in CRUSADE, with feedback provided to participating physicians and hospitals regarding their performance over time and compared with similar institutions. Such access to data has proved important in stimulating improvements in non-ST-segment elevation acute coronary syndromes care at participating hospitals for delivery of acute and discharge guideline-based therapy, as well as improving outcomes for patients. Providing quality improvement methods such as protocol order sets, continuing education programs, and a CRUSADE Quality Improvement Initiative toolbox serve to actively stimulate physician providers and institutions to improve care. The CRUSADE Initiative has also proven to be a fertile source of research in translation of treatment guidelines into routine care, resulting in more than 52 published articles and 86 abstracts presented at major emergency medicine and cardiology meetings. The cycle for research of guideline implementation demonstrated by CRUSADE includes four major steps–observation, intervention, investigation, and publication–that serve as the basis for evaluating the impact of any evidence-based guideline on patient care. Due to the success of CRUSADE, the American College of Cardiology combined the CRUSADE Initiative with the National Registry for Myocardial Infarction ST-segment elevation myocardial infarction program to form the National Cardiovascular Data Registry-Acute Coronary Treatment & Intervention Outcomes Network Registry beginning in January 2007.

PMID: 17967956 [PubMed - in process]

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Toward improved implementation of evidence-based clinical algorithms: clinical practice guidelines, clinical decision rules, and clinical pathways.

Acad Emerg Med. 2007 Nov;14(11):1015-22

Authors: Gaddis GM, Greenwald P, Huckson S

This is a summary of the consensus-building workshop entitled “Guideline Implementation and Clinical Pathways,” convened May 15, 2007, at the Academic Emergency Medicine Consensus Conference, “Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake.” A new term, “evidence-based clinical algorithms” is suggested to encompass evidence-based information codified into clinical pathways, clinical practice guidelines, and clinical decision rules. Examples of poor knowledge translation (KT) relevant to the specialty of emergency medicine are identified, followed by brief descriptions of important research and concepts that inform the research recommendations. Four broad themes for research to improve the KT of evidence-based clinical algorithms are suggested: organizational factors, cognitive factors, social factors, and motivational factors. In all cases, research regarding optimizing KT for the subthemes identified by Glasziou and Haynes, “getting the evidence straight,” and “getting the evidence used,” are interwoven into the thematic research recommendations. Consensus was reached that the majority of research efforts to evaluate means to improve KT need to be centered on the factors that show promise to enhance “getting the evidence used,” focused especially on organizational factors.

PMID: 17967964 [PubMed - in process]

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Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, Assessment, and Initial Management.

Pediatrics. 2007 Nov;120(5):e1299-e1312

Authors: Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D,

OBJECTIVES. To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings. METHODS. By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee. RESULTS. Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan. CONCLUSIONS. This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

PMID: 17974723 [PubMed - as supplied by publisher]

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The impact of the ILCOR 2005 CPR guidelines on a physical fitness assessment: A comparison of old and new protocols.

Resuscitation. 2007 Oct 30;

Authors: Bridgewater FH, Zeitz C, Field J, Inglis A, Poulish K

OBJECTIVE: St. John Ambulance Australia has used the performance of CPR for 10min as a fitness test for its members. Recent changes in international guidelines for cardiopulmonary resuscitation caused concern that the new ILCOR protocol was more strenuous than the previous one. This study compared the two protocols to determine if there were significant differences and to allow an evidence-based decision on the continuation or modification of this practice. MATERIALS AND METHODS: We studied 26 subjects performing single-rescuer cardiopulmonary resuscitation on a manikin. Every subject did 10min cardiopulmonary resuscitation using each protocol. The study used a randomized cross-over design. The estimated maximum heart rate was calculated for each subject. Compression rate and effective ventilation (number and depth) were enforced by direct feedback. Subjective and objective measures of physical activity were recorded at regular intervals. RESULTS: The maximum percentage of estimated maximum heart rate achieved during 15:2 and 30:2 CPR was 76+/-2% and 79+/-2%, respectively (mean+/-standard error of mean; P

PMID: 17976891 [PubMed - as supplied by publisher]

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