Clinical Practice Guidelines For Management Research Articles

Fentanyl for Acute Pain Management

1 C THE OPIOID ANALGESIC fentanyl has long been used as an anesthetic analgesic and is rapidly gaining in popularity for the management of acute pain. The impetus for this may have been generated over 10 years ago when the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) Acute Pain Management Clinical Practice Guideline Panel advised clinicians to find alternatives to meperidine, which was the most common parenteral opioid analgesic administered for moderate to severe acute pain at that time. The panel cautioned that meperidine produces a metabolite (normeperidine) that can readily accumulate and cause central nervous system (CNS) toxicity. The American Pain Society has warned that meperidine doses greater than 600 mg/24 hours and for more than 48 hours places the patient at especially high risk. It is particularly dangerous in individuals with renal insufficiency, such as older adults and patients with sickle cell disease. Fentanyl, along with morphine and hydromorphone, was recommended as one alternative to meperidine.

Lipids and CVD management: towards a global consensus

Cardiovascular disease (CVD) is currently the leading cause of morbidity and mortality worldwide and its incidence is likely to increase. Multiple risk factors contribute to CVD. Elevated LDL-cholesterol (LDL-C) and triglyceride levels, low HDL-cholesterol levels, hypertension, type 2 diabetes, and smoking are key modifiable risk factors. Such risk factors are present in 80-90% of coronary heart disease (CHD) patients. For many factors, modification can significantly reduce CVD incidence. For example, statin-induced LDL-C reductions reduce cardiovascular events by 24-37% and smoking cessation reduces CHD mortality by 36%. The need to identify and treat these risk factors has led many national and local groups to develop clinical practice guidelines for management of CVD. Although the aim of such guidelines is to provide practitioners with a framework to identify, prioritize, and manage patients, the plethora of guidelines can cause confusion. In addition, research indicates that guidelines are not being optimally implemented. This review considers these practical issues, highlights the common goals shared by many guidelines, and focuses on how these can be best achieved. It also highlights areas where the guidelines differ and discusses points to consider when selecting the most appropriate recommendation.

Diagnosis and Management of Acute Otitis Media

The American Academy of Pediatrics and American Academy of Family Physicians have released a joint clinical practice guideline for management of acute

K/DOQI clinical practice guidelines for management of renal osteodystrophy in predialysis patients

Blood levels of PTH (parathyroid hormone) begin to rise when GFR falls below 60 mL/min/1.73 m2, and evidence of bone disease due to hyperparathyroidism may be present at Stage 3 of chronic kidney disease (CKD). IntactPTH(i-PTH) is a useful test in detecting high turnover bone disorder and low turnover bone disorder. The Work Group taken target range of serum i-PTH in predialysis patients by their opinion. Dietary phosphorus should be restricted when the serum levels of i-PTH are elevated above target range of CKD stage. If phosphorus and i-PTH levels can not be controlled within the target range, despite dietary phosphorus restriction, phosphate binders should be prescribed. Only calcium based phosphate binders are available in predialysis patients in Japan. To avoid soft tissue calcification, total elemental calcium intake should not exceed 2,000 mg/day. If vitamin D deficiency are present, vitamin D2 should be supplied. But we can't measure serum 25(OH) D and prescribe vitamin D2 in Japan. Low dose of active vitamin D sterols are effective on renal osteodystrophy in predialysis patient. Active vitamin D sterols should be prescribed from low doses and serum calcium levels and renal function should be checked frequently. It is necessary to evaluate this K/DOQI (Kidney disease outcomes quality initiative) guideline and to establish guideline in Japan.

Distress Management Clinical Practice Guidelines in Oncology

The evaluation and treatment model expressed in the NCCN Distress Management Guidelines recommends that each new patient be rapidly assessed in the office or clinic waiting room for evidence of distress using a brief screening tool (the Distress Thermometer and Problem List) presented in Figure 1 (see page 369). A score of 5 or greater on the thermometer should trigger further evaluation and referral to a psychosocial service. The choice of which service should be determined by the problem areas specified on the Problem List. Patients with practical and psychosocial problems are referred to social work, emotional or psychological (excessive sadness, worry, nervousness) problems to mental health, and spiritual concerns to pastoral counselors. The primary oncology team members--doctor, nurse, and social worker--are central to making this model work. Team members collect information from the brief screening and problem list and expand it with the clinical evaluation. It is critical for at least one team member to be familiar with the mental health, psychosocial, and pastoral counseling resources available in the institution and the community. A list of the names and phone numbers for these resources should be kept in all oncology clinics and updated frequently. The first step in implementing this model is to establish a multidisciplinary committee in each institution or office responsible for 1) revising and modifying the standards of care to fit the particular clinical care setting and 2) implementing and monitoring the use of these standards. Because each institution has its own culture, standards must be implemented in ways that are compatible with each institution. The second step is to institute professional educational programs to ensure that staff is 1) aware that distress is under-recognized, 2) knowledgeable about the management of distress, and 3) aware of the resources available to treat it. It is important to have access to mental health professionals and clergy who are trained to deal with cancer-related distress. The benefits of treating distress in cancer accrue to the patients and their families, to the treating staff, and to improved efficiencies in clinic operations. Health care contracts often allow these services to "fall through the cracks" by failing to reimburse for them through either behavioral health or medical insurance. Reimbursement for services to treat psychosocial distress must be included in medical health care contracts to prevent fragmentation of services for the medically ill. For patients with cancer, integration, not separation, of mental health services and medical services is critically important. Also outcomes research studies that include quality-of-life assessment and analysis of cost-effectiveness are needed. Patients and families should be informed that management of distress is part of their total medical care. Finally, the multidisciplinary committee, office practice, or institution must be responsible for evaluating the quality of the distress management (see guidelines algorithm [page 368]), with CQI studies making an important contribution. Presently, the quality of the psychological care patients receive is not routinely monitored. Accrediting bodies have not directly examined the quality of psychosocial care, nor have they established minimal performance standards for its delivery. The panel believes that psychosocial care should and will eventually be on our institution's report cards.

Treatment of diabetic retinopathy

Diabetic retinopathy is a major public health problem and it remains the leading cause of blindness in people of working age (20 to 65 years). Several important clinical trials have given us the evidence base to provide clinical practice guidelines for management of this disease. With full implementation of existing technology, it should be possible to greatly improve visual outcomes for people with diabetes. There are two keys to maintaining vision in people with diabetes. First, achieving good long‐term metabolic control of diabetes will limit the development and progression of diabetic retinopathy. Second, ensuring early detection of diabetic retinopathy by regular (two‐yearly at least) screening examinations will allow timely referral for application of retinal photocoagulation. This paper will review the ophthalmologist's treatment of diabetic retinopathy with emphasis on the role of photocoagulation.

A protocol for the pharmacologic treatment of major depression: A field test of a potential prototype

Background: Much attention is being given to developing clinical practice guidelines for management of mental health disorders. The aim of this study was to field test a prototype protocol for the pharmacologic treatment of Major Depression. Method: The protocol consisted of four, six week, treatment phases with critical choices in therapy defined by scores on the MADRS (Montgomery Åsberg Depression Rating Scale). Observational data as collected on the behaviour of the protocol in terms of relevance, acceptability, ease of use and effectiveness. Results: Effectiveness of the protocol was good for those patients who were retained within it, with three quarters of them attaining remission. However more than half of all patients dropped out—non attendance and adverse events being the most common reasons for this. Conclusion: The protocol for the treatment of Major Depression appeared relevant, easy to use and potentially effective. Limitation: Problems with non-adherence by both doctors and patients posed major challenges to the protocol's design. Such difficulties demonstrate the need to field test any proposed design as preconceptions about a protocol's performance may be misplaced. Clinical Relevance: The protocol tested represents progress towards the goal of developing optimal strategies for the use of pharmacotherapeutic agents in the treatment of depression.

Implementation of the AHCPR Clinical Practice Guideline on the Management of Cancer Pain

The 1994 Clinical Practice Guideline for Management of Cancer Pain published by the federal Agency for Health Care Policy and Research (AHCPR) was the basis for a cooperative project on cancer pain control conducted by the Utah peer review organization with a team of clinicians from seven acute care hospitals. The purpose of the project was to adapt the federal guideline into action plans for participating hospitals and provide the tools necessary to address six “core” issues, i.e., assess and relieve pain, educate the patient/family and health care workers, measure patient satisfaction, and provide a continuum of care post discharge. The issues were further adapted to meet the needs of the participating hospitals. Baseline data were collected on 10 patient records per hospital. Survey results confirmed that attitudes about cancer pain management were changing, but more needed to be done to prevent patient suffering. Follow-up data after one year showed significantly more compliance on all six core issues...

Cancer Pain Management: Pilot Implementation of the AHCPR Guideline in Utah

Using the Agency for Health Care Policy and Research's (AHCPR's) 1994 Clinical Practice Guideline for Management of Cancer Pain, HealthInsight, the peer review organization for Utah and Nevada, organized a cooperative project with physicians and nurses from seven acute care hospitals in Utah. The project's purpose was to adapt the guideline into action plans for participating hospitals and provide the tools necessary to address six "core" guidelines-to assess and relieve pain, educate the patient/family and health care workers, measure patient satisfaction, and provide a continuum of care postdischarge. GUIDELINE DEVELOPMENT: The guidelines were further adapted to meet the needs of the individual hospitals and were implemented in January 1995. Baseline data was collected on 10 patient records per hospital. Survey results confirmed that although attitudes about cancer pain management were changing, more needed to be done to prevent patient suffering. Follow-up data after one year showed significantly more compliance on all six core guidelines. The oncology nurse manager and the hematology/oncology physician chief at one hospital joined the project team to support their own ongoing efforts to implement the guidelines. At that hospital, patient satisfaction with pain management has since increased from the 60%-80% level to at least 90%. STATEWIDE PROJECT EXPANSION: Statewide expansion was planned in fall 1995 to extend implementation to the remaining acute care hospitals and to other health care settings in Utah and to ease a patient's transition from one setting to another. The project team continues to monitor progress in guideline implementation. Surveys demonstrate that, at the time of diagnosis, up to 45% of cancer patients experience moderate to severe pain; 65%-90% experience severe pain when cancer reaches the advanced stages. Unrelieved cancer pain can cause intense suffering, diminished activity, loss of appetite, and loss of sleep.

Improving Pain Management in Critical Care

In April 1994 at the University of California at Los Angeles Medical Center the Surgical Intensive Care Unit's (SICU's) Quality Improvement Council unanimously agreed on pain management as one of the major factors that negatively affect outcomes for their patient population. Using the FOCUS-PDCA (plan-do-check-act) model for quality improvement (QI), the council chartered a subcommittee to improve the pain management in their ICUs. The subcommittee first measured the pain assessment scores of patients at transfer from the ICU. After ascertaining that these scores were greater than the goal of 2, the process of providing pain relief was examined with the assistance of process control statistics, which showed a process barely capable of meeting the goal of pain score of 2 or less on a 0-5 scale. The process factors that affected this outcome were examined and changes were made where appropriate. One of these changes was development of a guideline for acute pain management based on the Agency for Health Care Policy Research's Acute Pain Management Clinical Practice Guideline. Reassessment of the pain scores and the process was then conducted. The pain assessment scores at transfer from the ICU decreased significantly. Thirty-five percent of patients in the preguideline survey rated their scores as greater than 2, compared with only 21% at the postguideline survey. Pain assessment and documentation also improved significantly. The Quality Improvement Council felt that improvements in pain management were due largely to their having provided staff with the right tools to use in assessing, documenting, and controlling pain. Gains in pain management continue to be made.