Care Clinical Practice Guidelines Research Articles

Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan

BackgroundDespite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan.MethodsA GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The “National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021” was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either “Adopt,” “Adapt” or “Exclude”. The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines.ResultsTwenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made.ConclusionThe described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Usefulness of Liquid Biopsy for Veteran Patients with Metastatic Lung Cancer

Abstract Introduction/Objective The National Comprehensive Cancer Network (NCCN) non-small cell lung cancer (NSCLC) Guidelines Panel strongly advises the use of broad molecular tumor profiling to identify rare driver mutations in patients with advanced or metastatic disease. This testing could either be performed on the tumor sample itself or from liquid biopsy with next generation sequencing. Liquid biopsy presents a minimally invasive opportunity to obtain molecular information from circulating tumor cells (CTC) that may impact treatment. However, the literature of metastatic lung cancers targeted by liquid biopsies and the mutations found is sparse, particularly for the veteran population. Methods/Case Report A retrospective review was performed of all patients with a submitted liquid biopsy specimen at a Veteran Affairs Medical Center (VAMC) from November 26th, 2019, to March 3rd, 2023, to exa mine those patients with metastatic lung cancer. Information on mutations detected was collected. Results (if a Case Study enter NA) There were a total of 35 patient specimens with a history of metastatic lung cancer, from which 34 cases had an available liquid biopsy report. The first liquid biopsy for a patient with metastatic lung cancer was sent on November 26th, 2019. Some of the more common mutations identified through the liquid biopsy included KRAS (7/34), TP53 (15/34), and TERT promoter (3/34). 5 of these 34 cases had no reportable genomic alterations detected. Conclusion Liquid biopsies are a non-invasive, powerful diagnostic tool that is highly useful for broad molecular tumor profiling for precise management and for appropriate counseling of patients on treatment as per the standard of care clinical practice guidelines (such as from the NCCN).

Sleep and critical illness: a review.

Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.

Interprofessional primary palliative care: Do the AACN Essentials prepare nurses for collaborative practice?

Palliative care specialists alone cannot meet the rising needs for palliative care. Primary palliative care, delivered interprofessionally by generalist health professionals, is essential to ensure equitable access. Educational competencies and clinical practice guidelines prepare these clinicians to integrate palliative care principles into practice. The purpose of this project was to evaluate how the AACN Essentials prepares entry-level professional nursing students to function as members of the interdisciplinary primary palliative care team, as described in the National Consensus Project (NCP) for Quality Palliative Care Clinical Practice Guidelines. A team of nurse educators utilized a crosswalk mapping process with the Essentials domains, the Competencies and Recommendations for Educating Undergraduate Nursing Students (CARES) statements, and the NCP Guidelines. All eight of the NCP domains align with the Essentials. There were clear areas of overlap between the documents and unique areas of emphasis. This project identifies how educational competencies and clinical guidelines can guide competent palliative care practice. It also describes how nurses are prepared to collaborate in the delivery of palliative care.

Nursing care and models of care in relation to older people in long-term care contexts: a scoping review protocol

IntroductionWhat nurses do and how they do it can influence older people’s experiences of the quality of long-term care. In addition, a clear role definition for nurses supports them in...

THE STATE OF HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART & STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY

THE STATE OF HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART & STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY

Quality of critical care clinical practice guidelines involving pharmacotherapy recommendations.

To assess the quality of critical care clinical practice guidelines (CPGs) involving pharmacotherapy recommendations. A systematic electronic search was performed using PubMed, MEDLINE, and Embase for critical care CPGs published between 2012 and 2022 and involving pharmacotherapy recommendations. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument was employed to appraise CPG quality through independent assessment by 2 appraisers. Twenty-one CPGs were evaluated. The number of recommendations in each guideline ranged from 2 to 250, with a total of 1,604 recommendations. The number of strong (vs weak) recommendations in each guideline ranged from 0 to 31, with a total of 116 strong recommendations, or 7.23% of the total number of recommendations. There was at least 1 pharmacist author for 9 (43%) of the guidelines. The AGREE II domains for which mean quality scores of evaluated guidelines were highest were scope and purpose (0.88; 95% CI, 0.85-0.92), rigor of development (0.80; 95% CI, 0.77-0.83), clarity of presentation (0.84; 95% CI, 0.81-0.87), and editorial independence (0.86; 95% CI, 0.79-0.94), while those for which mean scores were lowest were stakeholder involvement (0.69; 95% CI, 0.63-0.75) and applicability (0.49; 95% CI, 0.43-0.55). Involvement of a pharmacist in CPG development was associated with significantly higher scoring for stakeholder involvement (P = 0.0356). Strong recommendations accounted for less than 10% of the recommendations in the evaluated CPGs. Moreover, there are concerns related to guideline applicability (ie, advice or tools for putting recommendations into practice) and stakeholder involvement (ie, inclusion of individuals from all relevant groups). It is important to involve pharmacists in CPGs with pharmacotherapy recommendations.

Verification of Assayed Blood Gas Quality Control Ranges.

Blood gas quality control (QC) is an essential and mandatory part of a laboratory's quality plan. The acceptable QC range should be 2 SD from the mean value. The use of assayed QC material does not negate the responsibility of the laboratory to calculate the mean and 2 SD ranges of QC measurements for verification. Verifying assayed QC ranges is a Clinical Laboratory Improvement Amendment (CLIA) requirement. This study shows the results of assayed QC mean and 2 SD range verification from a blood gas analyzer. QC data from a blood gas analyzer were compared to manufacturer-provided mean and ranges. The percent difference between the measured mean and the manufacturer-provided mean was calculated to assess agreement. The measured SD was used to determine how many SD the manufacturer-provided ranges were from the measured mean. The largest difference in mean values was 2.27% > the manufacturer-provided mean. Forty-eight percent of all mean value comparisons showed a difference of 0%, and 71% were < 1%. The manufacturer-provided ranges were considerably wider than the measured 2 SD range, ranging from 2.4-75 SD. None of the manufacturer-provided ranges were deemed acceptable for clinical use. Our analysis validates the CLIA mandate and American Association for Respiratory Care Clinical Practice Guideline recommendation that laboratories must verify manufacturer-provided QC means and ranges and adjust QC means and ranges to match the performance of their blood gas analyzer.

A Critical Review of Clinical Practice Guidelines for Care of Transgender and Gender Diverse Children and Youth for Use by Primary Care Practitioners.

To examine and critique international clinical practice guidelines (CPGs) related to transgender and gender diverse children and youth and to assess the applicability of the guidelines to ethical and affirming primary care practice. A review was conducted to obtain English language clinical guidelines. Guidelines were obtained from electronic databases, medical associations, government agencies, and community organizations. Guidelines were critiqued by all authors using the AGREE II instrument. Nine documents were reviewed. Overall, there was agreement among reviewers that the scope, purpose, and clarity of presentation of the guidelines was carried out well. Areas identified for improvement in all guidelines included clarity/rigor of methodologic development, inclusion of community stakeholders, and transparency of editorial independence. The Endocrine Society Clinical Practice Guideline scored highest overall. Despite lower overall scores, other guidelines were identified as having strengths of practical utility within primary care and/or in the discussion of specific social, ethical, and cultural considerations of transgender care in differing contexts worldwide. The use of specific, high-quality CPGs can support primary care practitioners to provide gender-affirming care to children and youth. Methodologic improvement in the development of these CPGs is needed to ensure the best possible quality of care is being outlined.

Improving the Applicability and Feasibility of Clinical Practice Guidelines in Primary Care: Recommendations for Guideline Development and Implementation.

ObjectiveTo give recommendations for the development of primary care clinical practice guideline (CPG) to improve applicability and feasibility of primary care CPGs in China.DesignA two-round Delphi survey.MethodsA two-round Delphi survey including guideline development methodologists and clinical practitioners from six countries was conducted. In round one, participants were asked to raise special considerations for the development of primary care CPGs through open-ended questions. In round two, participants were asked to rate the level of agreement on each recommendation item generated by round one and to raise additional recommendations. Opinions from participants were reviewed by thematic analysis. Integrated results from the Delphi survey were validated by participants.ResultsThe necessity of developing recommendations for the development of primary care CPGs were consistently recognized by participants. The main recommendations of guideline development were generated as follows: (1) considering the context of primary care institutions and the applicability of existing guidelines for primary care in planning guideline; (2) involving primary care practitioners and patients in guideline groups; (3) considering the variation of health-care resources between primary care settings when developing recommendations; (4) presenting the difference of recommendations between primary care CPG and general CPG; (5) implementing more active education and training; and (6) considering the changing of primary care medical resource when updating guideline.ConclusionIn this study, we present recommendations to inform the development of clinical practice guidelines in primary care settings. Next steps will include merging these recommendations with general guideline development methods to inform the development of guidelines for primary care.

Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness.

The majority of Palliative Care (PC) clinicians report recently caring for a person with a Substance Use Disorder (SUD). The impact of an untreated SUD is associated with significant suffering but many PC clinicians report a lack of confidence in managing this population. This paper aims to demonstrate existing PC skills that can be adapted to provide primary SUD treatment. A comprehensive literature review was conducted on quality PC domains and core SUD treatment principles. To demonstrate the shared philosophy and skills of PC clinicians and SUD treatment, the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and resources outlining core Addiction Medicine and Nursing Competencies were used. There is an abundance of overlapping domains in PC and SUD treatment. This paper focuses on the domains of communication, team-based care, quality of life considerations, addressing social determinants of health, and adherence to ethical principles. In each section, the shared domain in PC and SUD treatment is discussed and steps to expand PC clinician's skills are provided. PC clinicians may be among the last healthcare touchpoint for persons with SUD, by naming the shared skills required in PC and evidenced-based SUD treatment, we challenge the field to undertake primary SUD treatment as part of its constant pursuit to better serve people living with serious illness.

A national collaborative to spread and scale paramedics providing palliative care in Canada: Breaking down silos is essential to success

A national collaborative has been launched in Canada to spread and scale up the Paramedics Providing Palliative Care model. This builds on the knowledge that paramedics in the 9-1-1 (emergency/unscheduled) and scheduled models of care are both historically and currently asked by the public to provide urgent symptom relief within the context of a palliative approach, and that approximately 40% of dying people visit the emergency department in the last two weeks of life despite 70% wishing to die at home. A model of care including a palliative care clinical practice guideline or protocol, specific training, and a mechanism for sharing of goals of care, has been proven to improve the palliative and end of life experience for patients with palliative care needs and their families. It increases the comfort and confidence of paramedics and has benefits to the broader health system. Meaningful and very broad stakeholder engagement and inter-sectoral collaboration is absolutely essential to the success of this innovative approach to care.

Global Integration of Palliative Nursing Education to Improve Health Crisis Preparedness.

COVID-19 has highlighted the need for universal palliative care access. Nurses require palliative care education throughout the trajectory of professional training to effectively achieve this vision. Review of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and use of educational exemplars highlight opportunities for improving palliative nursing education in academic and clinical settings. Consistently applying palliative care principles affects nursing outcomes across myriad domains of person-centered services. All nurses are responsible for delivering primary palliative care, but they cannot practice what they do not know. The End-of-Life Nursing Education Consortium Project offers evidence-based education for nursing students and practicing nurses nationally and globally. Equipping both nurses and nursing students with palliative care education is critical to improve the overall quality of health care throughout the continuum during COVID-19 and in the face of future health crises. [J Contin Educ Nurs. 2021;52(3):130-135.].

Comfort Needs of Cancer Family Caregivers in Outpatient Palliative Care.

Rapid expansion of outpatient palliative care has been fueled by the growing number of people living with cancer and other chronic illnesses whose symptoms are largely managed in the community rather than inpatient settings. Nurses and other palliative care professionals support seriously ill patients and their families, yet little research has specifically examined the needs of cancer family caregivers receiving services from outpatient palliative care teams. To address this gap in the knowledge base, researchers conducted a reflective thematic analysis of qualitative interviews conducted with 39 family caregivers, using Comfort Theory as a theoretical guide. Seven themes describing caregivers' comfort needs were identified, including the need to understand, need for self-efficacy, need to derive meaning, need for informal support, need for formal support, need for resources, and need for self-care. Findings have clear implications for palliative nursing, as they directly address cancer family caregivers' needs in 5 of the 8 domains of care delineated by the National Consensus Project for Quality Palliative Care's Clinical Practice Guidelines. Comprehensive, holistic nursing assessment is suggested to identify family caregivers' needs and plan for delivery of evidence-based interventions shown to decrease burden and improve quality of life.

Development of the SPARK family member web pages to improve symptom management for pediatric patients receiving cancer treatments

BackgroundSupportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web-based application that facilitates symptom screening and access to supportive care clinical practice guidelines (CPGs) for children and adolescents receiving cancer treatments. Objective was to develop SPARK family member web pages for pediatric patient family members accessing: (1) proxy symptom screening and symptom reports, and (2) care recommendations for symptom management based on CPGs.MethodsSPARK family member web pages were developed and included access to symptom screening and care recommendations sections. Care recommendations for fatigue and mucositis were created. These were iteratively refined based upon cognitive interviews with English-speaking family members ≥16 years of age until less than two participants incorrectly understood sections as adjudicated by two independent raters.ResultsA total of 100 family members were enrolled who evaluated the SPARK family member web pages (n = 40), fatigue care recommendation (n = 30) and mucositis prevention care recommendation (n = 30). Among the last 10 participants, none said that the SPARK family member web pages were hard or very hard to use, one incorrectly understood one web page, none said either care recommendation was hard to understand and none were incorrect in their understanding of the care recommendations.ConclusionsWe successfully developed SPARK web pages for use by family members of pediatric patients receiving cancer treatments. We also developed a process for translating CPG recommendations designed for healthcare professionals to lay language. The utility of SPARK family member web pages after clinical implementation could be a focus for future research.

What are the unmet supportive care needs of men affected by penile cancer? A systematic review of the empirical evidence

To systematically evaluate evidence regarding the unmet supportive care needs of men affected by penile cancer and their partners to create a holistic model of care and inform clinical practice guidelines. We searched CINAHL, MEDLINE, PsychINFO, Embase, and the Cochrane Library (CCRT and CDSR) controlled trials databases and clinicaltrial.gov from 1990 to April 2020. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. 18 articles were included, reporting the results from 17 studies. Included reports used qualitative (seven studies) and survey (ten studies). Across these studies, men reported that the diagnosis and subsequent treatment of penile cancer affected physical, psychological and sexual well-being with each facet impacting and being intertwined with the other at varying degrees. There was varying complexity of unmet needs in men and partners pre-surgery, post-surgery and into survivorship. Moderate evidence exists that men affected by penile cancer experience a range of unmet supportive care needs across the international literature. Further work to evaluate the impact of penile cancer on partners is required.

Generalist Palliative Care in the California Safety Net: A Structured Assessment to Design Interventions for a Range of Care Settings

To provide high quality care to all patients who have serious illness, health-care systems must develop effective generalist palliative care strategies. To identify palliative care quality gaps within a range of settings in the California safety net and to develop theory-based interventions to address them. Structured assessment using the National Consensus Project for Quality Palliative Care Clinical Practice Guidelines and a Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation intervention planning model-based worksheet, which integrates behavior theories to identify factors that predispose, enable, and reinforce clinicians to perform recommended behaviors. Adviser pairs-one from palliative care and one from a partner service line-from 10 California public health-care systems conducted assessments at their sites. A steering committee provided educational webinars, best practices, and assessment tools. Adviser pairs interviewed at least 6 partner service line stakeholders to identify palliative care quality gaps, behaviors clinicians should perform to close gaps, and factors that predispose, enable, and reinforce those behaviors. Partner service lines were primary care (n = 4), surgery (n = 3), emergency department (n = 2), and radiation oncology (n = 1). Selected gaps were advance care planning and goals of care communication (n = 6), identifying patients with serious illness (n = 3), and pain management (n = 1). All sites designed multiple interventions to address gaps, based on factors that predispose, enable, and reinforce a target audience to perform a target behavior. Advisers reported that the program strengthened relationships between palliative care and the partner service line. This structured assessment helped busy clinicians develop theory-based generalist palliative care interventions.

Airway Management in Prolonged Field Care.

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.

Primary Care Providers' Knowledge, Attitudes, Beliefs, and Practices Regarding Their Preparedness to Provide Cancer Survivorship Care.

Recent cancer care delivery models and clinical practice guidelines have expanded the role of primary care providers (PCPs) in routine follow-up of cancer survivors. We conducted a cross-sectional survey of PCPs affiliated with a large healthcare system to (1) examine practices, attitudes, and beliefs regarding preparedness to provide survivorship care and (2) explore predictors of confidence managing cancer survivors. We distributed a self-administered online survey to 1069 clinical affiliates providing primary care services within the University of Pittsburgh Medical Center system. Associations between PCPs' professional characteristics and attitudes and preparedness were evaluated. Multiple logistic regression explored predictors of confidence monitoring common cancer treatment-related symptoms. One hundred twenty-seven eligible PCPs responded. The sample was split between academic and community practice (48.0% vs. 52.0%, respectively), predominantly comprised of physicians (81.8%), and 64.6% had > 15years direct patient care experience. The majority agreed that PCPs play a valuable role in surveillance and adverse event monitoring in survivors, though less than 25% felt their professional training prepared them to perform each of these domains. Physicians were significantly more likely than advanced practice providers to be among the 65% of PCPs who were confident monitoring ≥ 1 symptom in each of the 5 evaluated symptom clusters (OR 3.6, 95% CI 1.2-10.8). PCPs appear willing to assume an enhanced role in cancer survivorship care but feel unprepared to do so. Enhanced training and dissemination of clinical practice guidelines are needed to facilitate effective implementation of PCP-delivered survivorship care.

Clinical practice outcomes and differential results in maternal and neonatal morbidity among pregnant women in Spain who are candidates for a normal birth: a cross-sectional study

ObjectiveTo determine the percentage of pregnant women who are potential candidates for a normal birth in the region of Cantabria, Spain. Also, to compare the main clinical practice outcome indicators...