Evidence-based Care Protocols Research Articles

Diagnostic concordance of telemedicine as compared to face-to-face care in primary health care clinics in rural India: a randomized crossover trial.

Background With the COVID-19 pandemic, there was an increase and scaling up of provider-to-provider telemedicine programs that connect frontline health providers such as nurses and community health workers at primary care clinics with remote doctors at tertiary facilities to facilitate consultations for rural patients. Considering this new trend of increasing use of telemedicine, this study was conducted to generate evidence for patients, health providers, and policymakers to compare if provider-to-provider telemedicine-based care is equivalent to in-person care and is safe and acceptable in terms of diagnostic and treatment standards. Objective This study aims to compare the diagnosis and treatment decisions from teleconsultations to those of in-person care in teleclinics in rural Gujarat. Methods We conducted a diagnostic concordance study using a randomized crossover study design with 104 patients at 10 telemedicine primary care clinics. Patients reporting to 10 telemedicine primary care clinics were randomly assigned to first receive an in-person doctor consultation (59/104, 56.7%) or to first receive a health worker–assisted telemedicine consultation (45/104, 43.3%). The 2 groups were then switched, with the first group undergoing a telemedicine consultation following the in-person consultation and the second group receiving an in-person consultation after the teleconsultation. The in-person doctor and remote doctor were blinded to the diagnosis and management plan of the other. The diagnosis and treatment plan of in-person doctors was considered the gold standard. Results We enrolled 104 patients reporting a range of primary health care issues into the study. We observed 74% (77/104) diagnostic concordance and 79.8% (83/104) concordance in the treatment plan between the in-person and remote doctors. No significant association was found between the diagnostic and treatment concordance and the order of the consultation (P=.65 and P=.81, respectively), the frontline health worker–doctor pair (both P=.93), the gender of the patient (both P>.99), or the mode of teleconsultation (synchronous vs asynchronous; P=.32 and P=.29, respectively), as evaluated using Fisher exact tests. A significant association was seen between the diagnostic and treatment concordance and the type of case (P=.004 and P=.03, respectively). The highest diagnostic concordance was seen in the management of hypertension (20/21, 95% concordance; Cohen kappa=0.93) and diabetes (14/15, 93% concordance; Cohen kappa=0.89). The lowest values were seen in cardiology (1/3, 33%) and patients presenting with nonspecific symptoms (3/10, 30%). The use of a digital assistant to facilitate the consultation resulted in increased adherence to evidence-based care protocols. Conclusions The findings reflect that telemedicine can be a safe and acceptable alternative mode of care especially in remote rural settings when in-person care is not accessible. Telemedicine has advantages. for the potential gains for improved health care–seeking behavior for patients, reduced costs for the patient, and improved health system efficiency by reducing overcrowding at tertiary health facilities.

Incontinence-Associated Dermatitis: Prevalence in Intensive Care Units and Knowledge, Attitudes, and Practices of Nurses.

Incontinence-associated dermatitis (IAD) is a major concern among hospitals, especially in intensive care units (ICUs). To describe ICU nurses' knowledge, attitudes, and practices of IAD and to examine the relationships with IAD prevalence in the ICU setting. A descriptive correlational design was used including the Knowledge, Attitudes and Practices of Incontinence-Associated Dermatitis Questionnaire and 1-month IAD prevalence data. The prevalence of IAD in ICUs was 6.89%. A positive correlation was found between IAD prevalence and nurses' IAD knowledge and attitudes. Nurses working in the ICU for more than 7 years, caring for patients at high risk for or having IAD, and thinking IAD-related nursing practices were sufficient had significantly higher IAD knowledge, attitudes, and practices. Findings indicate that ICU nurses learned about IAD through clinical experience and have inadequate training on IAD. A standardized evidence-based care protocol for IAD should be developed.

The 'Parma At-Risk mental states' (PARMS) program: General description and process analysis after 5 years of clinical activity.

From January 2016, the Parma Department of Mental Health developed a specialized care protocol - the 'Parma At-Risk Mental States' (PARMS) program - as a diffused service for early intervention in individuals at Clinical High Risk for Psychosis (CHR-P). The aims of this investigation were (1) to describe the PARMS structural organization and (2) to examine specific process indicators during the first 5 years of its clinical activity. All participants were adolescent and young adult help-seekers (aged 12-25 years) at CHR-P in accordance with well-defined psychometric criteria. At entry, 52 subjects were provided with a dedicated protocol of care and only 14 dropped out during the first year of treatment. The Duration of Untreated Illness (DUI) overall decreased over time. Most of CHR-P participants suffered from 'Attenuated Psychotic Symptoms' and 'Brief, Limited, Intermittent Psychotic Symptoms' in the same percentage (48.1% [n= 25]). The most common DSM-IV-TR diagnosis was schizotypal personality disorder, followed by borderline personality disorder and brief psychotic disorder. A specialized, evidence-based care protocol for CHR-P individuals within Italian adult and child/adolescent psychiatric services is feasible, also in adolescents, who have a high risk of falling through the child/adult service gap.

A qualitative study of nurse-perceived barriers to body temperature management in postoperative patients.

Although evidence-based practices exist for preventing hypothermia in patients during surgery, few studies have focused on this concern in postoperative patients. The aim of this qualitative study was to explore the most challenging issues experienced by surgical ward nurses while managing the body temperature of adult surgical patients. To address this research gap, this study used a qualitative descriptive design to document barriers to body temperature management as reported by a sample of 16 perioperative nurses. The semi-structured, face-to-face interviews were digitally recorded, transcribed verbatim and analysed using inductive content analysis. The main barriers fell into three categories: professional nursing ability limitations, unfavourable working conditions and management of human resources. The eight subcategories were disadvantageous professional views, professional knowledge limitations, low motivation to provide nursing care, non-standard treatment environment, inadequate equipment and care protocols, heavy nursing care loads, inadequate staff training and ineffective staff supervision. These findings highlighted the importance of adequate resources, proper education and evidence-based care protocols in the effective delivery of body temperature management to postoperative patients.

Abstract 16954: Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Cardiovascular Prevention Treatments in Patients With Coronary Artery Disease Insights From the Bridge Cardiovascular Prevention Cluster Randomized Trial

Introduction: Moving toward evidence-based care protocols is key to reduce the burden of cardiovascular diseases. Hypothesis: We assessed the hypothesis that a multifaceted intervention could improve the adherence to evidence-based therapies for coronary artery disease patients. Methods: The BRIDGE Cardiovascular Prevention study was a cluster randomized trial including 1,619 patients with ischemic stroke, coronary artery disease or peripheral artery disease from 40 outpatient clinics in Brazil. Clusters were randomized to receive a multifaceted quality improvement intervention or to routine practice. The intervention included reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint was the adherence to combined use of statins, antiplatelets and ACEi or ARBs, using an “all or none” approach at 12 months in patients without contra-indications. Results: Among the 1619 patients enrolled in the original sample, 1327 (81.9%) were coronary artery disease patients. The mean age was 65.7 (SD=10.4) and 880 (66.3 %) were men. There was a significant difference in the combined prescription of evidence-based therapies between the intervention and the control groups (75.4% versus 61.8 % respectively, Odds Ratio, 2.33 [95% CI, 1.29 - 4.21], p<0.01). Patients in the intervention group were more likely to receive statins (94.4% vs. 84.7%; Odds Ratio 4.15 [95% CI, 1.62 - 10.61], p<0.01) and antiplatelet (95.3% vs. 89.0%; Odds Ratio 3.32 [95% CI, 1.45 - 7.58], p<0.01). There was no significant difference in the occurrence of major cardiovascular events (non-fatal myocardial infarction, non-fatal stroke and mortality) between groups (2.34 % vs. 3.08%; Hazard Ratio 0.76 [95%CI, 0.39-1.49, p=0.42]. For patients with myocardial infarction the combined prescription of evidence-based therapies was increased in the intervention group as compared to the control group (75.6% versus 62.3 % respectively, Odds Ratio, 2.12 [95% CI, 0.99 - 4.54], p=0.02). Conclusions: Among coronary artery disease patients treated in Brazil, a quality improvement intervention resulted in improved prescription of evidence-based therapies for cardiovascular prevention.

Critically Ill Adults With Coronavirus Disease 2019 in New Orleans and Care With an Evidence-Based Protocol

BackgroundCharacteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown.Research QuestionWhat are the outcomes of critically ill adults with COVID-19 admitted to a network of hospitals in New Orleans, Louisiana, and what is an evidence-based protocol for care associated with improved outcomes?Study Design and MethodsIn this multi-center, retrospective, observational cohort study of ICUs in four hospitals in New Orleans, Louisiana, we collected data on adults admitted to an ICU and tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 9, 2020 and April 14, 2020. The exposure of interest was admission to an ICU that implemented an evidence-based protocol for COVID-19 care. The primary outcome was ventilator-free days.ResultsThe initial 147 patients admitted to any ICU and tested positive for SARS-CoV-2 constituted the cohort for this study. In the entire network, exposure to an evidence-based protocol was associated with more ventilator-free days (25 days; 0-28) compared with non-protocolized ICUs (0 days; 0-23, P = .005), including in adjusted analyses (P = .02). Twenty patients (37%) admitted to protocolized ICUs died compared with 51 (56%; P = .02) in non-protocolized ICUs. Among 82 patients admitted to the academic safety net hospital’s ICUs, the median number of ventilator-free days was 22 (interquartile range, 0-27) and mortality rate was 39%.InterpretationCare of critically ill COVID-19 patients with an evidence-based protocol is associated with increased time alive and free of invasive mechanical ventilation. In-hospital survival occurred in most critically ill adults with COVID-19 admitted to an academic safety net hospital’s ICUs despite a high rate of comorbidities.

Principles of dental care of transplanted patients

The number of organ transplants is being on the rise. State-of-the-art immunosuppressive therapies and modern peri- and postoperative care have significantly increased life expectancy of transplanted patients, therefore, dentists and oral surgeons may encounter these patients more frequently. Although the number of successful transplants in Hungary has recently exceeded ten thousand; there is still no dental treatment protocol for these patients. The authors aimed to review and analyse the international literature about the perioperative dental care of transplanted patients based on good practice and evidence-based care protocols. A review and comparative analysis of the English and Hungarian literature between 2010 and 2019 was conducted in relation to the objective pursued. The number of scientific papers in this topic is limited and their level of evidence is low. In our paper, the risk factors of transplantation and the cornerstones of perioperative, early and late postoperative dental management are described. Organ-specific considerations and possible oral manifestations of the applied medications are also presented. Lifelong administered immunosuppressive medications and the resulting artificially weakened immune system require increased attention from dentists and other healthcare professionals during patient aftercare. Close cooperation between the treating physician/surgeon and the dentist is essential to maintain patient safety. Moreover, inflammatory disorders may put the patients at increased risk, so maintaining good oral hygiene is essential. Regular dental check-ups, early detection and adequate therapy can be the cornerstones of long-term uncomplicated survival. Orv Hetil. 2020; 161(36): 1506-1513.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis

BackgroundAppendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. MethodsIn 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. ResultsAmong the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). ConclusionsThis study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

Implementation of a Successful Enhanced Recovery after Surgery Program in a Community Hospital.

BackgroundEnhanced recovery after surgery (ERAS) protocols have been shown to be effective at accelerating return to functioning, reducing length of stay, and reducing cost per encounter at major medical centers and health systems across the United States and Europe. Implementation in the community hospital setting has been considered more challenging due to a wide range of factors. This study demonstrates the successful creation of such a program in a community hospital in central North Carolina.MethodsStarting in the spring of 2016, an anesthesiology-led, multidisciplinary ERAS team was formed with the purpose of developing an enhanced recovery after major urologic surgery program. A clinical protocol was developed by the team that met quarterly to review metrics. Outcome data were collected by chart review and compared to pre-ERAS values in a retrospective, nonrandomized, consecutive fashion and underwent statistical analysis.ResultsOverall, a reduction in both average and median length of stay (37% reduction) was observed in the post-ERAS group along with a reduction in 90-day readmission. Statistical analysis confirmed a very strong likelihood (p<.0001) that the ERAS protocol resulted in the observed reduction in the length of stay.DiscussionThis study demonstrated the feasibility of starting an ERAS program in a community hospital as well as the critical role that anesthesiology leadership can provide. An anesthesiology-led ERAS program offers a solution to some of the challenges faced by community hospitals regarding variable and silo-based care. ERAS pathways aim to implement standardized and coordinated evidence-based care protocols through multidisciplinary teams representing the entirety of the surgical encounter, leading to more consistent and favorable outcomes for patients and hospitals. This model can be applied to many other services in addition to the major urology effort described here.

P007: Safety and effectiveness of a care protocol to treat migraine with Propofol in the emergency department

Introduction: An evidence-based care protocol to treat migraine with low-dose Propofol was implemented in May 2014 at the emergency department (ED) of the CHUL (Québec city). Given potential side effects of Propofol, we aimed to evaluate the safety and effectiveness of this protocol. Methods: We reviewed charts of all patients aged 16 years and older who received Propofol between May 2014 and August 2017 for a migraine headache with or without aura, as defined in the International Headache Society Classification. The care protocol consisted of: 1) administration of intra-venous Propofol 20 mg each 5 to 10 minutes as needed (maximum of 6 doses); 2) sets of vital signs before and after each dose; and 3) continuous cardiac and saturation monitoring. Our primary outcome measures were the incidence (95%CI) of the following side effects: low arterial pressure (&lt; 90 systolic or &lt; 65 mean), desaturation (SaO2&lt;92%), excessive sedation (scores 3 or 4 on the Pasero scale), and any arrhythmia. We also compared the mean reduction (95%CI) of pain pre- and post-treatment (visual analogous scale VAS 0-10) and the proportion (95%CI) of rescue medication among patients who received Propofol as first-line medication to a matched cohort of patients who had Metoclopramide first. The two cohorts were paired for gender, age, triage priority, and month/year of ED visit. Results: Over the 3-year study period, 45 patients with migraine received Propofol through the care protocol, either as a first-line or a rescue therapy. In this cohort, hypotension, bradycardia (&lt;60/min) and desaturation occurred in 17.8% (8.0-32.1), 13.3% (5.1-26.8) and 6.7% (1.4-18.3) of cases respectively; no excessive sedation was reported. An intervention was undertaken in 4 cases [8.9% (2.5-21.2) 3 iv fluid bolus, 1 supplemental oxygen] to palliate the side effects of Propofol. A statistically significant mean reduction of 3.6 points (2.8-4.4) on the VAS scale was observed in patients treated with Propofol as first-line therapy (n=35). However, patients managed with first-line Metoclopramide (n=100) experienced a significantly higher mean reduction of their VAS score [5.3 (4.6-6.0)] than the Propofol group (p=0.003). The proportion of patients requiring the use of rescue medication was higher among patients first treated with Propofol [77.1% (63.2-91.1) vs. 29.0% (20.1-37.9); p&lt;0.001]. Conclusion: Our care protocol to treat migraine with low doses of Propofol appears to be safe and to cause very few side effects prompting corrective interventions. Continuous (as opposed to intermittent) heart and saturation monitoring is probably not indicated. Given the effectiveness of Propofol compared to Metoclopramide, our care protocol will be used as a second-line therapy.

Integrated Dementia Care in the Center for Geriatrics and Gerontology at Kaohsiung Veterans General Hospital

Due to the increasing aging and dementia populations all over the world, Taiwan has followed the global action plan to propose the seven key action areas. As one key action area, the authors conducted a systematic literature review regarding the diagnosis, treatment, care, and support of patients with dementia and their caregivers. The findings of a systematic literature review suggest that the case management model could be applied for dementia care; however, the evidence is still weak because of the roles and intensity of case managers, as well as their communication skills. Except for the literature review, the authors also introduced the center for geriatrics and gerontology at Kaohsiung Veterans General Hospital in southern Taiwan providing as the integrated dementia care. Additionally, 10-year long-term care plan 2.0 of Taiwan was also introduced and compared with the systems of integrated dementia care. Based on this model of long-term care provision, the Center for Geriatrics and Gerontology at Kaohsiung Veterans General Hospital has potential to be an A level center, the daycare center and aforementioned three dementia care units could function as B level care centers, and the Double-Bliss Welfare and Charity Foundation, as well as other local community organizations and activity centers, could provide C level care services. Furthermore, the correspondent author held the 2018 comprehensive practicum conference for integrated care of patients with dementia from January 19 to February 22, 2018 in collaboration with 19 nursing faculties from various nursing schools. Finally, the correspondent author intends to conduct further research in collaboration with the Center for Geriatrics and Gerontology at Kaohsiung Veterans General Hospital to further develop the “3D” (delirium, dementia, and depression) assessment scale and evidence-based care protocols.

Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study.

BackgroundEven though previous research has demonstrated improved outcomes of integrated care initiatives, it is not clear why and when integrated care works. This study aims to contribute to filling this knowledge gap by examining the implementation of integrated care for type 2 diabetes by two Dutch care groups.MethodsAn embedded single case study was conducted including 26 interviews with management staff, care purchasers and health professionals. The Context + Mechanism = Outcome Model was used to study the relationship between context factors, mechanisms and outcomes. Dutch integrated care involves care groups, bundled payments, patient involvement, health professional cooperation and task substitution, evidence-based care protocols and a shared clinical information system. Community involvement is not (yet) part of Dutch integrated care.ResultsBarriers to the implementation of integrated care included insufficient integration between the patient databases, decreased earnings for some health professionals, patients’ insufficient medical and policy-making expertise, resistance by general practitioner assistants due to perceived competition, too much care provided by practice nurses instead of general practitioners and the funding system incentivising the provision of care exactly as described in the care protocols. Facilitators included performance monitoring via the care chain information system, increased earnings for some health professionals, increased focus on self-management, innovators in primary and secondary care, diabetes nurses acting as integrators and financial incentives for guideline adherence. Economic and political context and health IT-related barriers were discussed as the most problematic areas of integrated care implementation. The implementation of integrated care led to improved communication and cooperation but also to insufficient and unnecessary care provision and deteriorated preconditions for person-centred care.ConclusionsDutch integrated diabetes care is still a work in progress, in the academic and the practice setting. This makes it difficult to establish whether overall quality of care has improved. Future efforts should focus on areas that this study found to be problematic or to not have received enough attention yet. Increased efforts are needed to improve the interoperability of the patient databases and to keep the negative consequences of the bundled payment system in check. Moreover, patient and community involvement should be incorporated.

The Impact of Business Intelligence on Healthcare Delivery in the USA

Introduction To improve healthcare quality, safety, and efficiency is an economic and national necessity. The role of technology to ensure healthcare quality and control cost is an ongoing debate within the industry and a subject of interest to researchers. Delivering quality healthcare requires the integration of patient health information from many different sources and availing a diverse set of users; health providers must be able to readily access and use the right information at the right time and patients should be able to access their health information in order to be able to self-manage their conditions. Supporters of the adoption of advanced technology in healthcare consider it as an opportunity not only to enhance the quality of health services, but also transparency of economic activities and the availability of information in real time (Mettler, 2009). As technology has enhanced diagnosis and treatment options and since lifesaving medicines are entering the market at an increasing rate, life expectancy is on the rise. Healthcare organizations are investing millions in computer systems, diagnostic technology, and preventive care programs in an attempt to meet healthcare quality goals. These developments, however, come with a huge price tag. Health care costs now consume nearly 18 percent of the U.S. GDP (Ramsey, Ganz, Shankaran, Peppercorn, & Emanuel, 2013). Payers face difficulties compensating providers for high-cost treatments made possible by advances in technology. Claims that are inflated as well as outright fraudulent are intensifying the problem. The payers and providers in the healthcare industry, public and private, are looking into technology to costs, while keeping the quality care intact. The predicament doesn't end with the notion of quality versus cost; the healthcare industry is experiencing more scrutiny and complexity than any other single industry in modern history. Health providers and the affiliates have to understand and respond to privacy laws and information security. In addition, a vast range of factors such as health care practice regulations, patient records and requirements, practice and staff management, training, financial stability, facilities and equipment management influence the holistic view of quality healthcare. Another force altering the current condition of healthcare in the United States is the passing of the Patient Protection and Affordable Care Act (PPACA). Healthcare industry is under pressure to costs and better manage care. Burke and Ingraham (2008) note that healthcare in the U.S. is at the point of colossal change. The entire industry is struggling with the notion of management of quality and cost metrics. Intensified focus on compliance with evidence-based care protocols and, a staggering number of reimbursement programs affect revenue and the ability to compete. Healthcare industry executives must evaluate an increasing amount of information to best assess their organization's wellbeing and future. Furthermore, data overload is a common problem for many care providers and executive teams, who are grappling with too much information and looking to find ways to simplify acquiring knowledge from raw data (Byrnes, 2012). Coddington (2012) argues that decision-support capabilities allow collecting data from multiple sources, such as cost accounting systems, electronic health records and other sources, and make them available to physicians and other users. He suggests that a balance between cost control and the other priorities of healthcare organizations is necessary to provide quality care. The most important issue surrounding quality healthcare is the development of measurement goals to find validated metrics. Since usually high quality is perceived to be correlated with high cost, a statement such as reduce costs, while keeping the quality care intact, sounds paradoxical. However, Process improvement initiatives facilitated by business intelligence solutions constitute a cost-effective option. …

Subcutaneous administration technique of low-molecular-weight heparins: An integrative review

Anti-coagulant drugs for subcutaneous injection, like low-molecular-weight heparins (LMWH), are increasingly used to prevent and treat thromboembolic events, with local adverse reactions. The aim in this integrative review was to identify and analyze knowledge production about the most appropriate SC injection technique of LMWH to reduce hematomas, bruising and local pain. The following inclusion criteria were used: papers published in English, Spanish and Portuguese; between the first week of August 2001 and the last week of August 2012. Papers in which LMWH was compared with unfractionated heparin in the assessment of the outcomes and papers without statistical data analysis were excluded. The searches were undertaken in the electronic databases PubMed/MedLine, CINAHL, Scopus, Web of Science and LILACS/IBECS. The quality of the articles was assessed with the critical appraisal tool JBI MAStARI. The incidence of bruising ranged between 20%, when the application time of the injection was 30s, and 88.9% when it took 10s. In 50% of the studies, the authors concluded that LMWH injections taking 30s caused lower levels of bruising, with statistically significant differences, as well as a reduction in pain intensity in the injection site by up to 50%. The group that received LMWH through a prefilled syringe, with or without aspiration, showed lower levels of bruising. The formation of a skinfold, the 90º angle and the abdomen as the application site have been well documented in the literature. These findings are important for clinical nursing practice, as they found the elaboration of evidence-based care protocols and contribute to the improvement of patient care quality.

Rehabilitative Protocols for Select Patellofemoral Procedures and Nonoperative Management Schemes

There is a paucity of evidence-based care protocols for the management of patellofemoral (PF) joint conditions. There remains ambiguity in defining conditions; PF pain, malalignment, instability are intersecting patient cohorts in clinical practice. Treatment should address muscle strength deficits as well as movement pattern dysfunctions frequently observed in association with PF conditions. Quadriceps muscle dysfunction has significant heterogeneity in its etiology. The hip contributes to PF pathology as a consequence of femoral internal rotation and adduction. Inadequate gluteus medius ans maximus muscle performance is associated with kinematic flaws. Various surgical procedures are employed to address PF instability and associated pain patterns. Postoperative progressions should respect specific demands for bony healing, soft tissue healing and/or ligamentous graft incorporation. Symptomatic cartilage lesions may limit return to full function. Physical performance testing activities can be useful to measure patient progress and advise on return to activity/play.

Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified Reactive Delphi procedure. Part 2: methodology, analysis and results.

This is the second part of the article based on the thesis work for a Masters of Science in Wound Healing and Tissue Repair, Cardiff University, to develop an evidence-based protocol for the care of pilonidal sinus wounds (PSWs) healing by secondary intent, using a modified Reactive Delphi process. The sample included surgeons, clinic physicians, nurses and enterostomal therapy nurses experienced in the care of these wounds. Item generation involved an extensive review of the literature to identify key aspects of evidence-based wound care essential to wound healing, infected wounds and pilonidal wounds healing by secondary intent and drawing on clinical experience. The participants responded via an electronic Delphi website, using a 4-point Likert rating scale and a ranking system. Comments were invited. Feedback was provided to the participants at the end of each round, that included comments, consensus scores, content validity index and additional information that provided rationale and references, or minor revision if requested. This project successfully achieved the objectives, which were to identify the areas of care that negatively or positively influences healing of postoperative PSWs and to inform, educate and broaden the considerations regarding these factors for health care professionals.

Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified reactive Delphi procedure. Part one: the literature review*.

This article is in two parts. The overall aim of this section was to review the literature in relation to pilonidal sinus wounds (PSW) healing by secondary intent for a Master's of Science in Wound Healing and Tissue Repair thesis. The purpose of the literature review was to determine if an evidence-based guideline or consensus document existed for the care of these wounds, and if not, to determine the topics from which to develop items for the first round of a modified reactive Delphi questionnaire. Part two will describe the iterative process, the analysis and the results. The review found no best practice guidelines concerning PSW, and only one clinical pathway. Seventeen areas of interest were identified that may contribute to optimal healing conditions or to delayed healing. These included microbiology of infected PSW, signs and symptoms of localised or deeper (spreading) chronic wound infection, swab for c&s, role of topical antiseptics or antimicrobials, systemic antibiotics, local wound interventions, optimal positioning, wound cleansing, principles of moist wound healing/dressing selection, topical negative pressure (TNP) therapy, peri-wound skin decontamination and depilation, pain control, physical activities, optimal nutrition and patient education.

Promoting Evidence-Based and Measurement-Based Care

Imagine that major auto manufacturers have announced a quality breakthrough. Going forward, they will produce each model of car by using a standard set of parts assembled in the same order. And before selling any vehicle, they will test to be sure it can both start and stop. As auto consumers, we might not celebrate this breakthrough. Instead we might ask, “What has taken you so long?” The learning collaborative program described by Vannoy and colleagues in this issue deserves celebration. Primary care and mental health clinics serving disadvantaged patients can successfully implement integrated care programs for mood disorders, including evidence-based care protocols and systematic outcome assessment. However, evidence-based depression care guidelines have existed for 20 years, and standard depression outcome measures have existed for 40. So consumers might ask, “What has taken you so long?” Unfortunately, spreading evidence-based and measurement-based mental health care is not as straightforward as improving auto manufacturing. Some providers fear that evidence-based care means “cookbook medicine,” precluding personalization for individuals. In addition, organized mental health outcome measurement raises concerns about privacy of sensitive information. Neither of these concerns, however, actually argues against evidence-based or measurement-based care. The supposed conflict between evidence-based mental health care and personalized care is rooted in misunderstanding; the two are completely compatible. If we hope to choose the best treatment for any individual, we require two things. First, we need better evidence regarding how individual characteristics (such as symptom patterns and genetic variation) predict response to specific treatments. Our evidence must extend beyond average effectiveness to consider individual differences. Second, we need accurate measurement of how individuals differ in pre-treatment characteristics and in response to specific treatments. Better evidence and better measurement are therefore essential to personalizing care. Conflict between personalized care and evidence-based care arises only if we are personalizing care to meet the needs of providers. That is, unfortunately, sometimes the case. Privacy concerns regarding measurement-based care are also sometimes misplaced. Consumers’ privacy concerns focus more on sensitive personal details than on standard outcome questionnaires. In contrast, providers’ privacy concerns often reflect a wish to avoid scrutiny regarding quality or safety. Consumers’ privacy deserves protection; unsafe or ineffective care has no right to privacy. None of these comments are intended to dispute the importance of the collaborative efforts that Vannoy and colleagues describe. Instead they are intended as an apologetic answer to the question, “What has taken you so long?” We can celebrate the success of these learning collaboratives and also hope for a day when such success is no longer a newsworthy breakthrough.

Ambulances: From Antiquity to Modern Times

There has been much evolution and progress in the Emergency Medical Services systems worldwide. Today, it is not just a basic means of transporting the sick and injured to hospitals, but represents organised care and management of patients in the prehospital environment. Survival rates, in many instances, depend upon the proper management of these out-of hospital casualties and patients before they arrive at a healthcare facility. Issues such as state-of-the-art treatment, evidence based care protocols, medical accountability and professionalism have surfaced prominently. From the days of the first land and air ambulances, we have indeed come a long way.

Care of skeletal pins: a literature review.

Using the literature reviewed in this article, the author explores the issues surrounding wound care management in relation to care of skeletal pin sites. In this way, an evidence-based protocol for care is developed.