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[Audit on preoperative cardiac evaluation before non-cardiac surgery: The importance of a pocket guide to improve the anaesthesist's adhesion to ACC/AHA guidelines.]

Ann Fr Anesth Reanim. 2009 Oct 28;

Authors: Madi-Jebara S, Chalhoub V, Jabbour K, Yazigi A, Haddad F, Richa F, El-Hage C, Yazbeck P

INTRODUCTION: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder. METHODS: The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier. RESULTS: During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease. DISCUSSION: The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery.

PMID: 19879104 [PubMed - as supplied by publisher]

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[Audit on preoperative cardiac evaluation before non-cardiac surgery: The importance of a pocket guide to improve the anaesthesist's adhesion to ACC/AHA guidelines.]

Ann Fr Anesth Reanim. 2009 Oct 28;

Authors: Madi-Jebara S, Chalhoub V, Jabbour K, Yazigi A, Haddad F, Richa F, El-Hage C, Yazbeck P

INTRODUCTION: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder. METHODS: The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier. RESULTS: During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease. DISCUSSION: The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery.

PMID: 19879104 [PubMed - as supplied by publisher]

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< ![CDATA[

[Audit on preoperative cardiac evaluation before non-cardiac surgery: The importance of a pocket guide to improve the anaesthesist's adhesion to ACC/AHA guidelines.]

Ann Fr Anesth Reanim. 2009 Oct 28;

Authors: Madi-Jebara S, Chalhoub V, Jabbour K, Yazigi A, Haddad F, Richa F, El-Hage C, Yazbeck P

INTRODUCTION: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder. METHODS: The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier. RESULTS: During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease. DISCUSSION: The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery.

PMID: 19879104 [PubMed - as supplied by publisher]

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Nasal intermittent positive pressure ventilation in the newborn: review of literature and evidence-based guidelines.

J Perinatol. 2009 Oct 22;

Authors: Bhandari V

Various modes of nasal continuous positive airway pressure have been well established as a means of providing non-invasive respiratory support in the neonate. Recent reports suggest that nasal intermittent positive pressure ventilation may offer a better alternative, as a mode of non-invasive ventilation. This article will critically review the literature and provide some practical guidelines of the use of this technique in neonates.Journal of Perinatology advance online publication, 22 October 2009; doi:10.1038/jp.2009.165.

PMID: 19847188 [PubMed - as supplied by publisher]

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3D CT-based volumetric dose assessment of 2D plans using GEC-ESTRO guidelines for cervical cancer brachytherapy.

Brachytherapy. 2009 Oct 21;

Authors: Gao M, Albuquerque K, Chi A, Rusu I

PURPOSE: To investigate two-dimensional (2D) radiograph-based plans using three-dimensional (3D) dose-volume histogram (DVH) parameters following guidelines from Gynecologic GEC-ESTRO Working Group (GEC-ESTRO). METHODS AND MATERIALS: Nineteen high-dose-rate (HDR) fractions from 8 patients were studied. Prescription was 45Gy from external beam radiation therapy plus 30Gy in five fractions from HDR using tandem and ring/ovoids. Both radiographs and CT scan were obtained. Treatment was planned using radiographs following American Brachytherapy Society (ABS) guidelines. Retrospective evaluation of above 2D plans on a 3D volumetric basis was achieved by generating CT image-based 3D plans using same dwell times. RESULTS: In 2D plans, International Commission on Radiation Units and Measurement (ICRU) bladder and rectal point doses were 3.8+/-0.4 and 3.0+/-0.5Gy, respectively. In 3D plans, rectum D(2cc) is 4.0+/-1.0Gy and bladder D(2cc) is 5.4+/-0.9Gy. Position of actual hottest spot in 3D rectum volume was close to the position of ICRU rectal point. ICRU bladder point did not match with the actual hottest spot in 3D bladder volume. In 2D plans, H-point dose was 5.8+/-0.2Gy. In 3D plans, dose to CT-based cervix (D(90)) reduced from 7.1 to 4.2Gy as the cervical volume increased from 12 to 39cc. Average D(2cc)/ICRU dose ratio was calculated to be 1.36/1.01 for bladder/rectum, respectively. CONCLUSIONS: The DVH analysis of 2D plans revealed a suboptimal coverage of CT-based cervix and a negative correlation between coverage and cervical size. Rectum dose to 2cc weakly correlated with ICRU point dose. Currently published constraint for bladder in 3D planning is tighter than ABS guidelines in past 2D planning.

PMID: 19853536 [PubMed - as supplied by publisher]

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[Guideline: Treatment of obstructive sleep apnea in adults.]

HNO. 2009 Oct 25;

Authors: Verse T, Bodlaj R, de la Chaux R, Dreher A, Heiser C, Herzog M, Hohenhorst W, Hörmann K, Kaschke O, Kühnel T, Mahl N, Maurer JT, Pirsig W, Rohde K, Sauter A, Schedler M, Siegert R, Steffen A, Stuck BA,

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC’s Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a”S2e guideline”. Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

PMID: 19855948 [PubMed - as supplied by publisher]

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Implementation of a multidisciplinary guideline-driven approach to the care of the extremely premature infant improved hospital outcomes.

Acta Paediatr. 2009 Oct 26;

Authors: Nankervis CA, Martin EM, Crane ML, Samson KS, Welty SE, Nelin LD

Aim: To test the hypothesis that implementing guidelines for the standardized care of the extremely premature infant (<27 weeks) in the first week of life would improve patient outcomes in an all referral NICU. Methods: Data were collected on all infants <27 weeks gestational age and <7 days of age on admission cared for using these small baby guidelines (SBG), as well as on all age-matched infants admitted the year prior (comparison). Results: Thirty-seven patients were cared for utilizing the SBG and 40 patients were in the comparison group. There were no differences between the groups in gestational age, birthweight or age on admission. There was no difference in survival to discharge (73% SBG, 70% comparison). The mean length of stay for survivors was 112 +/- 38 days SBG and 145 +/- 76 days (p < 0.05) comparison group. Survival without BPD was greater in the SBG group (24%) than in the comparison group (9%; p < 0.05), and survival without severe IVH was greater in the SBG group (65%) than in the comparison group (38%; p < 0.01). Conclusions: These data demonstrate that applying a unified approach to the care of the extremely premature infant in the first week of life resulted in a decrease in the length of hospitalization and improved patient outcomes.

PMID: 19863632 [PubMed - as supplied by publisher]

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Ceftriaxone for Refractory Acute Otitis Media: Impact of a Clinical Practice Guideline.

Pediatr Emerg Care. 2009 Oct 27;

Authors: Gauthier M, Chevalier I, Gouin S, Lamarre V, Abela A

OBJECTIVE:: To determine the effect of a clinical practice guideline (CPG) on the use of ceftriaxone for the treatment of refractory acute otitis media (AOM) at a tertiary care pediatric hospital. METHODS:: Charts of all patients aged 3 to 60 months referred from an emergency department to a day treatment center for management of refractory AOM with ceftriaxone were reviewed. Data were collected during two 18-month periods before and after implementation of a CPG developed by a local group of experts. Ceftriaxone was indicated for children with symptomatic AOM despite 48 hours of treatment with high-dosage amoxicillin or amoxicillin-clavulanate (>75 mg/kg per day) or despite receiving 1 of these 2 antibiotics over the previous month. Overall treatment was considered adequate if patients met these indications for ceftriaxone, if at least 3 daily doses had been prescribed, and if all doses were within the 40- to 60-mg/kg range. RESULTS:: Thirty-two emergency physicians referred 127 patients to the day treatment center (60 preimplementation and 67 postimplementation of the CPG). The mean (SD) patient ages were 16.7 (7.4) and 19.7 (12.4) months in the preimplementation and postimplementation groups, respectively. Indications for prescription of ceftriaxone were adequate in 16.7% of the preguideline and 22.4% of the postguideline groups (P = 0.4). Physicians were twice as likely to use ceftriaxone adequately after the guideline's implementation, but this result was not statistically significant (crude odds ratio, 2.2; 95% confidence interval, 0.5-9.0). CONCLUSIONS:: Implementation of a CPG for the treatment of refractory AOM with ceftriaxone did not improve indications for its use.

PMID: 19864968 [PubMed - as supplied by publisher]

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The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance.

Implement Sci. 2009 Oct 29;4(1):71

Authors: Flanagan ME, Ramanujam R, Doebbeling BN

ABSTRACT: BACKGROUND: The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. METHODS: Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--Chronic Obstructive Pulmonary Disease, Chronic Heart Failure, and Major Depressive Disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. RESULTS: For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. CONCLUSION: Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

PMID: 19874607 [PubMed - as supplied by publisher]

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Guidelines on stability evaluation of vaccines.

Biologicals. 2009 Oct 27;

Authors:

PMID: 19875304 [PubMed - as supplied by publisher]

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