Dissemination Of Clinical Practice Guidelines Research Articles

Barriers and facilitators of adherence to clinical practice guidelines in Germany-A systematic review.

Clinical Practice Guidelines (CPGs) represent evidence-based tools designed to assist healthcare practitioners and patients in decisions in clinical practice. Evidence supports the clinical benefits of adhering to CPGs. However, their successful implementation and adherence in clinical settings often encounter challenges. This systematic review aimed to explore barriers and facilitators influencing adherence to CPGs in Germany. The protocol of this study was registered in the Open Science Framework (OSF) registry (DOI: 10.17605/OSF. IO/GMFUB). In November 2022 we searched on PubMed and Embase for primary studies employing qualitative, quantitative and mixed-methods approaches that focus on barriers or facilitators to CPGs adherence in the Germany. Two reviewers independently screened articles, extracted data, and evaluated the quality of the studies. The collected data on barriers and facilitators of CPG adherence were systematically categorized and analyzed using the Theoretical Domains Framework (TDF). A total of 24 studies were included, mainly focusing on adherence to national CPGs. This review introduces a new domain, guideline characteristics, reflecting the need to address barriers and facilitators to CPG development, implementation, dissemination and format, which couldn't be encompassed within the existing 14 domains of TDF framework. Among healthcare professionals, the most frequently reported influencing factors were related to the environmental context and resources (encompassing aspects such as employer support for CPG utilization), the CPG development and dissemination process (including layout, wording, and interactive tools) and beliefs about consequences (such as contradictions with practical experience). Knowledge (knowledge about the content of CPGs, awareness about published CPGs), primarily as a barrier, and reinforcement facilitators (notably financial support), were also frequently reported. The findings revealed multilevel factors contributing to CPG adherence, with environmental context and resources emerging as the most frequently reported considerations. This systematic review offer holistic insights into the barriers and facilitators of CPG adherence in Germany. The results contribute to a better understanding of the topic and serve as a resource for developing targeted strategies to enhance CPG adherence and implementation within the German healthcare system.

Common Mistakes in Managing Patients with Inflammatory Bowel Disease.

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

Diagnosis and Management of Biliary Strictures: A Clinical Practice Guideline Dissemination Tool.

Diagnosis and Management of Biliary Strictures: A Clinical Practice Guideline Dissemination Tool.

Improving the quality of clinical practice guidelines in China: A call to action for editors of medical journals

High-quality clinical practice guidelines (CPGs) have the potential to standardize medical practice and improve patient outcomes. However, in China, the quality of CPGs is generally lower than the global average, particularly in terms of methodological and reporting quality. This hinders the dissemination and implementation of CPGs in healthcare practice. To enhance the scientific rigor and authority of CPGs, their development should adhere to reporting guidelines. As medical journals serve as the platform for CPG publication, editors of medical journals have a significant responsibility for the quality control of publishing CPGs. We call on editors of medical journals to be equipped with the CPG reporting guidelines, implement them in their journal practice, and actively participate in the development of CPGs. Additionally, editors of medical journals can also promote CPG quality awareness among medical professionals and journal editors. These efforts will contribute to the high-quality development of CPGs in China.

How to improve the dissemination of clinical practice guidelines in the Brazilian Unified Health System? Report of a pilot project

In Brazil, there have been some initiatives to improve the development of Ministry of Health clinical protocols and therapeutic guidelines (PCDTs in Portuguese, and clinical practice guidelines—CPGs, in English) and their implementation so that best practices can be disseminated and adopted at multiple levels of health systems. One of the initiatives was to conduct a pilot project to improve the format of these CPGs. The objective of this article is to present the processes and results of the pilot project, including the development of a new standardized format for CPGs to promote national dissemination and uptake. The pilot project was designed in three phases: identification and selection of strategies to effectively implement clinical practice guidelines, definition of the ideal characteristics for the format of CPGs, and development and implementation of the new format. Initially, an overview of systematic reviews was conducted to map the global evidence on the effectiveness of dissemination and implementation strategies of CPGs. Among the most effective interventions, a low-cost strategy was selected to improve the format of CPGs, namely a full format and a short format. The two formats were evaluated for usefulness and acceptability by professionals who use or develop CPGs, and after several reiterations, the formats were finalized, considering the progression of care (from diagnosis of the disease to treatment, including specific technologies indicated in each stage of the disease). Related to the technical aspects, the visual presentation of the CPGs was improved, ensuring that key information was easily identified for decision-making by end users. The initial phase of implementation involved 33 clinical conditions, equating to approximately 20% of published CPGs. It is anticipated that disseminating the CPGs in the new formats will promote the accessibility of information and implementation of standardized CPGs by health professionals in the public health sector (servicing more than 210 million Brazilians). Further research should be considered to determine the impact of the use of the new CPGs formats, contributing to the knowledge base related to the implementation of guidelines in Brazil and internationally.

Remarks on "Temporomandibular Disorders: Priorities for Research and Care": how will Chile advance?

Temporomandibular disorders (TMDs) are complex multi-system disorders for which common traditional dental-centric approaches to research and care unfortunately continue to prevail. A committee appointed by the National Academies of Sciences, Engineering and Medicine (NAM) of the United States of America summarized important recommendations regarding the urgent need to transform, from the predominantly biomedical model, the research, professional education/training, and patient care for TMDs into the biopsychosocial model that is standard in the rest of pain medicine. The release of the Consensus Study Report identifies eleven short-term and long-term recommendations regarding gaps and opportunities oriented towards the situation in the US, which are equally applicable to the situation in Chile. The first four recommendations focus on basic and translational research, public health research and strengthening clinical research. The next three recommendations concern risk assessment, diagnostics, and dissemination of clinical practice guidelines and care metrics to improve patient care and expand its access. Recommendations eight to ten propose Centers of Excellence for Temporomandibular Disorders and Orofacial Pain Treatment, improving professional school education, and expanding specialized continuing education for healthcare providers. The eleventh recommendation focuses on patient education and stigma reduction. This article highlights the published recommendations and addresses what should be considered by Chilean professionals, as a first step of a major effort to shift TMD research, treatment, and education paradigms for the years to come.

Evaluating the impact of incorporating clinical practice guidelines for the management of infectious diseases into an electronic application (e-app).

To improve dissemination and accessibility of guidelines to healthcare providers at our institution, guidance for infectious syndromes was incorporated into an electronic application (e-app). The objective of this study was to compare empiric antimicrobial prescribing before and after implementation of the e-app. This study was a before-and-after trial. A tertiary-care, public hospital in Halifax, Canada. This study included pediatric patients admitted to hospital who were empirically prescribed an antibiotic for an infectious syndrome listed in the e-app. Data were collected from medical records. Prescribing was independently assessed considering patient-specific characteristics using a standardized checklist by 2 members of the research team. Assessments of antimicrobial prescribing were compared, and discrepancies were resolved through discussion. Empiric antimicrobial prescribing before and after implementation of the e-app was compared using interrupted time-series analysis. In total, 237 patients were included in the preimplementation arm and 243 patients were included in the postimplementation arm. Pneumonia (23.8%), appendicitis (19.2%), and sepsis (15.2%) were the most common indications for antimicrobial use. Empiric antimicrobial use was considered optimal in 195 (81.9%) of 238 patients before implementation compared to 226 (93.0%) 243 patients after implementation. An immediate 15.5% improvement (P = .019) in optimal antimicrobial prescribing was observed following the implementation of the e-app. Empiric antimicrobial prescribing for pediatric patients with infectious syndromes improved after implementation of an e-app for dissemination of clinical practice guidelines. The use of e-apps may also be an effective strategy to improve antimicrobial use in other patient populations.

Determinants of Awareness of Clinical Practice Guidelines among Healthcare Users in Japan.

Clinical practice guidelines (CPGs) are used by both healthcare users and providers, so their recognition is important. The present study's purpose was to clarify the features of healthcare users who are aware of the CPGs. A cross-sectional survey was conducted targeting Internet survey panels (n = 6000). The study participants (age range, 20s to 60s) had no medical qualifications and had received medical care in the last 3 months. Multivariate logistic regression analysis was performed to clarify the factors related to the awareness of CPGs. When "I have seen the CPGs" was used as the objective variable, the odds ratios (ORs) were high for "e-health literacy/score 31-40" (OR = 8.72, 95% confidence interval [CI]: 6.51-11.68), "Sources of health information/healthcare workers and professionals" (OR = 2.61, 95% CI: 2.17-3.14), "Age/20s" (OR = 2.38, 95% CI: 1.74-3.23), and "I have been diagnosed and treated for a major illness" (OR = 2.01, 95% CI: 1.52-2.65). These results could be applied to aid the dissemination and utilization of CPGs among healthcare users.

Overview of clinical practice guideline development, application to pharmacy practice, and roles for pharmacists

AbstractAll health care professionals have a responsibility to integrate current evidence‐based medicine into their clinical practice to ensure the best possible patient care. Clinical practice guidelines (CPGs) play a major role in helping clinicians identify when and how to implement evidence into routine clinical practice to improve patient outcomes. The primary intent of CPGs is to benefit patients by improving the quality of care; however, CPGs also improve efficiency and effectiveness within the health care system. The process used to develop CPGs is important to ensure the recommendations are trustworthy, based on the highest‐quality evidence, and free of significant conflicts of interest. The National Academy of Medicine (NAM) published guidance on best practices for developing CPGs in 1990 and again in 2011. Additional guidance is provided by various reporting checklists for CPGs, such as the Appraisal of Guidelines for Research & Evaluation (AGREE) II and Reporting Items for Practice Guidelines in Healthcare (RIGHT) instruments. However, analyses of published CPGs show inconsistent application of these best practices. This paper discusses the benefits of CPGs, reviews the guideline development process, discusses limitations in this process and in applying CPGs to patient care, identifies opportunities for improvement, provides considerations for educating learners and other health care professionals about CPGs, and examines the role of pharmacists in CPG development, dissemination, and implementation.

2021 Thalassaemia International Federation Guidelines for the Management of Transfusion-dependent Thalassemia.

Beta-thalassemia and particularly its transfusion-dependent form (TDT) is a demanding clinical condition, requiring life-long care and follow-up, ideally in specialized centers and by multidisciplinary teams of experts. Despite the significant progress in TDT diagnosis and treatment over the past decades that has dramatically improved patients’ prognosis, its management remains challenging. On one hand, diagnostic and therapeutic advances are not equally applied to all patients across the world, particularly in several high-prevalence eastern regions. On the other, healthcare systems in low-prevalence western countries that have recently received large numbers of migrant thalassemia patients, were not ready to address patients’ special needs. Thalassaemia International Federation (TIF), a global patient-driven umbrella federation with 232 member-associations in 62 countries, strives for equal access to quality care for all patients suffering from thalassemia or other hemoglobinopathies in every part of the world by promoting education, research, awareness, and advocacy. One of TIF’s main actions is the development and dissemination of clinical practice guidelines for the management of these patients. In 2021, the fourth edition of TIF’s guidelines for the management of TDT was published. The full text provides detailed information on the management of TDT patients and the clinical presentation, pathophysiology, diagnostic approach, and treatment of disease complications or other clinical entities that may occur in these patients, while also covering relevant psychosocial and organizational issues. The present document is a summary of the 2021 TIF guidelines for TDT that focuses mainly on clinical practice issues and recommendations.

Adaptation and Dissemination of Korean Medicine Clinical Practice Guidelines for Traffic Injuries.

In South Korea, car insurance that includes medical coverage of traditional Korean medicine (TKM) has increased exponentially. Clinical practice guidelines (CPG) for traffic injuries were established in 2016. We aimed to revise and update de novo CPG and distribute the adapted CPG to TKM practitioners and patients. Clinical key questions from previous CPG were identified and updated regarding the grade of recommendation and level of evidence using additional evidence from the literature obtained through a systematic search and the use of the Grading of Recommendations Assessment, Development, and Evaluation methodology. The dissemination and implementation of the updated CPG were conducted at the CPG Center of Korean Medicine. Ultimately, 25 recommendations based on 13 clinical key questions were developed: 2 for diagnosis, 22 for TKM treatments, and 1 for prognosis. After recognition by professional societies and certification by the CPG Center of Korean Medicine, leaflets, card news, and infographics for TKM doctors in South Korea were produced and distributed. These are the only TKM CPG for patients who have experienced traffic injuries. They are expected to contribute to standardized and evidence-based treatment using TKM and similar interventions. Moreover, disseminating the adapted CPG will promote treatment reliability and strengthen insurance coverage.

Are We Actually Guided by Clinical Practice Guidelines?: Commentary on an article by Kevin Y. Zhu, BS, et al.: "Hyaluronic Acid Injections for Knee Osteoarthritis. Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?"

Commentary Medical practitioners are presented with substantial data regarding potential interventions for musculoskeletal problems. The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) organize and summarize the available data regarding numerous nonoperative and operative treatments for musculoskeletal problems, including the management of knee osteoarthritis (OA). While the recommendations of the CPGs are often somewhat limited by the lack of quality research, the 2013 AAOS CPG cited moderate evidence against the routine use of hyaluronic acid (HA) injections for the management of symptomatic knee OA. The study by Zhu et al. provides an excellent evaluation of the use of HA injections in Medicare patients, both before and after the CPG was published, as well as an analysis of the financial impact of continued HA use. Knee OA remains highly prevalent and is a substantial economic burden in the United States. Intra-articular injections have long been a mainstay in the nonoperative treatment of the disease; however, recent publications have demonstrated some concerns with corticosteroid injections, particularly when they are performed close to the time of total knee arthroplasty (TKA)1. Unfortunately, similar risk has been demonstrated with HA injections2. The data surrounding the clinical efficacy of HA injections also are quite variable, but in most comparative studies, little benefit is seen over the use of nonsteroidal anti-inflammatory drugs, corticosteroid injections, biologics, or even normal saline solution3,4. The most important finding of the present study is that despite the moderate recommendation against the routine use of HA in the 2013 AAOS CPG, as well as its high cost and questionable clinical efficacy when compared with numerous other treatments, there has not been a significant decline in the use of HA in Medicare beneficiaries. This finding is supported by and expands on an earlier survey study that reported HA to be the most popular choice for management of moderate-grade knee OA5. This finding, while not surprising, is disappointing as it is clear that either the message of the CPG is not being effectively disseminated to the practitioners who are managing knee OA with HA injections, or the evidence is simply being ignored due to a lack of other options for this challenging population of patients. A second important finding of this study is the substantial financial burden that HA injections continue to pose on the health-care system. A cost averaging >$300 million a year is significant and worthy of highlighting. Zhu et al. demonstrated that this cost steadily increased throughout the study period and likely will continue to increase. Given the lack of demonstrated clinical efficacy in large systematic reviews and high-level studies, it is hard to justify these costs for HA use. Recent studies have shown that even emerging treatments such as biologics and platelet-rich plasma (PRP) may be more cost-effective than HA injections6. A finding of the study that may explain some of the discordance between the AAOS recommendations and HA utilization is that advanced practice providers (APPs) contributed significantly to the national increase in utilization that was seen over the study period. Many practices have transitioned interventions such as injections to APPs. It is very possible that evidence from the CPG has not effectively been distributed to APPs. The true cause is likely multifactorial. There are many patients with advanced knee OA who are simply not ready for TKA or are not good candidates for TKA since the requirements for optimization of medical comorbidities continue to become stricter. Many patients will not find any relief from corticosteroid injections, and as long as HA injections are available, they represent another possible therapeutic option, despite the evidence against the routine use of HA. While biologics such as PRP have shown promising benefits in the management of knee OA, insurance companies still do not cover this cost, and many patients cannot afford cash payments for prolonged treatment. Value-based care continues to be the focus of health-care practitioners, health systems, and insurers. When CPGs offer conclusive recommendations based on available evidence, it is worthwhile to evaluate their effects on practice patterns. The trends observed in the study by Zhu et al. demonstrated that despite the high cost and low clinical efficacy of HA injections, in addition to a CPG recommending against its routine use, there has been no appreciable decline in the use of HA injections among Medicare beneficiaries within the 5 years following publication of the CPG. This highlights the importance of wide dissemination of CPGs to physicians and APPs, as well as the need for more cost-effective treatments for knee OA.

Management of Patients on Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Peri-Endoscopic Period: A Clinical Practice Guideline Dissemination Tool

Barkun, Alan N. MD, MSc (Epi), FACG, CAGF1; Douketis, James MD2; Noseworthy, Peter A. MD3; Laine, Loren MD, FACG4; Telford, Jennifer J. MD, MPH, FACG, CAGF5; Abraham, Neena S. MD, MSc (Epi), FACG6 Author Information

Management of Chronic Rhinosinusitis Prior to Otolaryngology Referral: An Opportunity for Quality Improvement.

The management of chronic rhinosinusitis (CRS) by a nonotolaryngologist prior to otolaryngology referral is an important component of the patient care pathway. The purpose of this study is to characterize CRS management during this period and to identify areas of quality improvement. Retrospective review of a national claims database. Academic institution. Data were analyzed from the IBM Health MarketScan Research Databases (2013-2017). Patients with 3-year enrollment data were identified who were initially diagnosed with CRS by a nonotolaryngologist and subsequently seen by an otolaryngologist. Management of CRS by the nonotolaryngologist was assessed in terms of duration, demographics, health care resource utilization, and health care expenditure. A total of 51,273 patients met inclusion criteria. The median length of the referral period was 142 days, with variations according to geography. Patients with a delayed referral period had higher health care resource utilization in terms of visits for CRS (mean, 1.8 vs 1.2), total visits (mean, 12.6 vs 3.9), and medication prescriptions (especially antibiotics; mean, 5.8 vs 2.1). Health care expenditure was almost twice as high for the delayed referral group (mean, $986 vs $571), mainly due to CRS-related medication costs (mean, $578 vs $214). Our findings suggest that there are wide variations in how CRS is managed prior to referral to an otolaryngologist. The dissemination of clinical practice guidelines to primary care providers may help to increase efficiency of CRS care and offers a unique opportunity for quality improvement that extends beyond the bounds of our own specialty.

A Web Interface for Antibiotic Prescription Recommendations in Primary Care: User-Centered Design Approach.

BackgroundAntibiotic misuse is a serious public health problem worldwide. National health authorities release clinical practice guidelines (CPGs) to guide general practitioners (GPs) in their choice of antibiotics. However, despite the large-scale dissemination of CPGs, GPs continue to prescribe antibiotics that are not recommended as first-line treatments. This nonadherence to recommendations may be due to GPs misunderstanding the CPGs. A web interface displaying antibiotic prescription recommendations and their justifications could help to improve the comprehensibility and readability of CPGs, thereby increasing the adoption of recommendations regarding antibiotic treatment.ObjectiveThis study aims to design and evaluate a web interface for antibiotic prescription displaying both the recommended antibiotics and their justifications in the form of antibiotic properties.MethodsA web interface was designed according to the same principles as e-commerce interfaces and was assessed by 117 GPs. These GPs were asked to answer 17 questions relating to the usefulness, user-friendliness, and comprehensibility and readability of the interface, and their satisfaction with it. Responses were recorded on a 4-point Likert scale (ranging from “absolutely disagree” to “absolutely agree”). At the end of the evaluation, the GPs were allowed to provide optional, additional free comments.ResultsThe antibiotic prescription web interface consists of three main sections: a clinical summary section, a filter section, and a recommended antibiotics section. The majority of GPs appreciated the clinical summary (90/117, 76.9%) and filter (98/117, 83.8%) sections, whereas 48.7% (57/117) of them reported difficulty reading some of the icons in the recommended antibiotics section. Overall, 82.9% (97/117) of GPs found the display of drug properties useful, and 65.8% (77/117) reported that the web interface improved their understanding of CPG recommendations.ConclusionsThe web interface displaying antibiotic recommendations and their properties can help doctors understand the rationale underlying CPG recommendations regarding antibiotic treatment, but further improvements are required before its implementation into a clinical decision support system.

Difficult Airway Management in Adult Coronavirus Disease 2019 Patients: Statement by the Society of Airway Management.

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Harnessing mobile technology to deliver evidence-based maternal-infant care

mHealth, the use of wireless and portable communication technology to improve the health status of the population, has seen widespread adoption in low- and middle-income countries. It has been used to increase awareness and knowledge of healthcare, to collect health-related data, to deliver healthcare information such as results of investigations or appointment reminders, to aid decision-making by healthcare providers, and to improve communication between various stakeholders of the health system. Developing countries face an immense challenge of periodically updating the professional knowledge of their huge pool of community and facility level healthcare workers. Nearly universal possession of mobile phones, low-cost internet data, and high growth rate of smartphones has facilitated the use of mHealth in delivering evidence-based guidelines and decision-aids to frontline healthcare workers. This review describes the current evidence on the use of mHealth educational interventions targeting maternal and neonatal healthcare providers in low- and middle-income countries. Recent efforts of the National Neonatology Forum of India in integration of mHealth for development and dissemination of clinical practice guidelines are also presented.

A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT. Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively. The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention. Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.

Effectiveness of Implementation Strategies to Improve Adherence of Physical Therapist Treatment Choices to Clinical Practice Guidelines for Musculoskeletal Conditions: Systematic Review.

The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists' treatment choices to clinical practice guidelines for a range of musculoskeletal conditions. For this review, searches were performed in several databases combining terms synonymous with "practice patterns" and "physical therapy" until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists' treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed. Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study). Although this review revealed limited trials evaluating interventions to increase physical therapists' use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective. Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists' adherence to clinical practice guidelines for a range of musculoskeletal conditions.

4340 Piloting Implementation and Dissemination of Best Practice Guidelines Using BPM+Health

OBJECTIVES/GOALS: Clinical translational studies inform clinical practice patterns through dissemination of clinical practice guidelines (CPG). In EM practices change to rapidly for timely local EHR implementation. We test the OMG BPM+Health specification for rapid deployment of best practices relevant to EM. METHODS/STUDY POPULATION: The OMG Business Process Management for Healthcare (BPM+Health) specification combines BPMN™ with Case Management Model and Notation (CMMN™) and Decision Model and Notations (DMN™) to “disseminate and leverage evidence-based best-practices at the point of care.” The American College of Emergency Physicians (ACEP) Board-certified Emergency Physicians modeled practice guidelines in the BPM+ modeling language during on-line meetings. Two common emergency conditions were selected for initial pilot testing: 1) evaluation and treatment of first trimester bleeding in pregnant patients, and 2) the evaluation and treatment of non-traumatic low back pain. RESULTS/ANTICIPATED RESULTS: The protocols were successfully modeled during four on-line meetings in less than 2 months. Process steps from initial evaluation to disposition were implemented using BPMN™. When clinicians need to evaluate the patient to collect data for decision making the inputs and outputs were modeled in CMMN™. Decision logic is represented as DMN™. The software tool linked the components for easy browsing and authoring the logic. The Physicians easily followed the displayed logic. The practice recommendations from each policy were successfully modeled, using the standard BPM+ notation to support rapid implementation in EHRs. Detailed implementation specifications will be shared. DISCUSSION/SIGNIFICANCE OF IMPACT: This pilot project demonstrated the feasibility of the OMG approach to solving Clinical Practice Guideline Implementation and Dissemination Barriers. Ongoing work by involved specialty societies will be necessary to demonstrate the scalability and sustainability of this approach.