Guideline Compliance Research Articles

Systematic basic and advanced resuscitation training in medical students and fellows: a proposal from the Working Group on Cardiovascular Urgences and Emergencies of the Italian Society of Cardiology.

Sudden cardiac arrest is a leading cause of death in Europe. High-quality cardiopulmonary resuscitation (CPR) and guidelines compliance of rescuers have been associated with better outcomes after cardiac arrest. However, wide variability in attempting bystander CPR manoeuvres has been reported. Educational programmes for teaching CPR to medical students and fellows are highly advisable in this context. However, there is no homogeneity regarding the CPR education offered by academic institutions. We surveyed 208 Italian medical students and 162 fellows in cardiology regarding the educational offer and needs in CPR. Among the 11 medical schools surveyed, 8 (73%) offer basic (BLS) courses but only 3 (38%) with formal certification of 'BLS provider', while none offers advanced (ACLS/ALS) courses. Among the 30 specialization schools in cardiology surveyed, 10 (33%) offer a BLS course (6 with formal certification of 'BLS provider'), and 8 (27%) offer an ACLS/ALS course (5 with formal certification). Only a minority of students and fellows perceive themselves as highly proficient either in BLS or ACLS/ALS, although most of the fellows were involved at least once in rescuing a cardiac arrest. The present position paper analyses and suggests the strategies that should be adopted by Italian medical and specialization schools to spread the CPR culture and increase the long-standing retention of CPR-related technical and nontechnical skills.

Conflicts of Interest Among Infectious Diseases Clinical Practice Guideline Authors and the Pharmaceutical Industry

This cross-sectional study assesses the prevalence of conflicts of interest (COI) associated with guideline-recommended drugs among Infectious Diseases Society of America clinical practice guideline authors and compliance with the Council on Medical Specialty Societies and Institute of Medicine guidelines.

Implementation of the Kidney Disease Improving Global Outcomes guidelines for the prevention of acute kidney injury after cardiac surgery: An international cohort survey.

Increasing evidence from randomised controlled trials supports the implementation of a six-measure care bundle proposed by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines in patients at high risk for acute kidney injury (AKI) to reduce its incidence after cardiac surgery. To assess compliance with the KDIGO bundle in clinical practice. Prospective observational multinational study. Six international tertiary care centres, from February 2021 to November 2021. Five hundred and thirty-seven consecutive patients undergoing cardiac surgery during a 1-month observational period. All patients were assessed for the postoperative implementation of the following measures: avoidance of nephrotoxic medication and radiocontrast agents whenever possible, strict glycaemic control, close monitoring of renal function, optimisation of haemodynamic and volume status and functional monitoring of haemodynamic status. The primary endpoint was the proportion of patients receiving fully compliant care. Secondary outcomes were occurrence of AKI and major adverse kidney event rate at day 30. The full care bundle was applied to 0.4% of patients. There was avoidance of nephrotoxic drugs in 15.6%, radiocontrast agents in 95.3% and hyperglycaemia in 39.6%. Close monitoring of urine output and serum creatinine was achieved in 6.3%, 57.4% underwent optimisation of volume and haemodynamic status, and 43.9% received functional haemodynamic monitoring. 27.2% developed AKI within 72 h after surgery. The average number of implemented measures was 2.6 ± 1.0 and did not differ between AKI or non-AKI patients ( P = 0.854). Adherence with the KDIGO bundle was very low in cardiac surgery patients. Initiatives to improve guideline compliance might provide a strategy to mitigate the burden of AKI. www.drks.de DRKS00024204.

Validation of the Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) quality assessment tool.

The Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) was developed to undertake streamlined quality audits of antifungal prescribing. The validity and reliability of such tools is not characterized. To assess the validity and reliability of the AF-NAPS quality assessment tool. Case vignettes describing antifungal prescribing were prepared. A steering group was assembled to determine gold-standard classifications for appropriateness and guideline compliance. Infectious diseases physicians, antimicrobial stewardship (AMS) and specialist pharmacists undertook a survey to classify appropriateness and guideline compliance of prescriptions utilizing the AF-NAPS tool. Validity was measured as accuracy, sensitivity and specificity compared with gold standard. Inter-rater reliability was measured using Fleiss' kappa statistics. Assessors' responses and comments were thematically analysed to determine reasons for incorrect classification. Twenty-eight clinicians assessed 59 antifungal prescriptions. Overall accuracy of appropriateness assessment was 77.0% (sensitivity 85.3%, specificity 68.0%). Highest accuracy was seen amongst specialist (81%) and AMS pharmacists (79%). Prescriptions with lowest accuracy were in the haematology setting (69%), use of echinocandins (73%), mould-active azoles (75%) and for prophylaxis (71%). Inter-rater reliability was fair overall (0.3906), with moderate reliability amongst specialist pharmacists (0.5304). Barriers to accurate classification were incorrect use of the appropriateness matrix, knowledge gaps and lack of guidelines for some indications. The AF-NAPS is a valid tool, assisting assessors to correctly classify appropriate prescriptions more accurately than inappropriate prescriptions. Specialist and AMS pharmacists had similar performance, providing confidence that both can undertake AF-NAPS audits to a high standard. Identified reasons for incorrect classification will be targeted in the online tool and educational materials.

Echinocandin use in an Australian tertiary hospital: implications for antifungal stewardship

AbstractBackgroundInvasive candidiasis (IC) surveillance demonstrates an increasing incidence of resistance to azole‐based therapy. Consequently, echinocandins are often considered first‐line treatment for IC in critically ill patients. To better understand the complexities of decision‐making around echinocandin initiation, an evidence‐based audit tool was developed.AimTo describe echinocandin initiation and compliance with current guidelines.MethodA retrospective audit of echinocandin initiation was conducted between 1 January 2020 and 31 December 2020 at a quaternary referral hospital. An audit tool was developed by infectious diseases physicians and antimicrobial stewardship pharmacists, capturing patient demographics, microbiological results, indication for therapy, and risk factors for invasive fungal disease (IFD). Local guideline compliance was determined. This project was determined to be a quality improvement project and was not required to undergo ethical review according to the Alfred Hospital Ethics Committee procedures.ResultsOne hundred sixty‐seven patients were initiated on 214 courses of echinocandin therapy. Caspofungin was most commonly prescribed (n = 172, 80%). Of the 167 patients, most (n = 119, 71%) were in the intensive care unit at the time of initiation. Empiric therapy for sepsis or infection of unclear source was the most commonly documented indication (n = 117, 55%); 71% (n = 153) of all courses were deemed empiric therapy, followed by directed therapy (n = 55, 26%). The most common risk factors for IFD were recent exposure to broad‐spectrum antimicrobial therapy (n = 165, 99%) and the presence of a urinary catheter (n = 141, 84%). Most first doses were compliant with local guidelines (n = 144, 67%).ConclusionsEchinocandin therapy was commonly prescribed in critically ill patients with risk factors for IFD. Although the majority of prescriptions were empiric and compliant with local guidelines, improved guidelines incorporating additional patient factors should be included in future antifungal stewardship initiatives.

Perioperative management of diabetes audit (POMODA)

BackgroundSuboptimal perioperative management of diabetes is associated with postoperative morbidity and mortality. Australian healthcare providers should primarily be guided by the Australian Diabetes Society Perioperative Diabetes Management Guidelines in caring for the perioperative diabetic patient when local or state guidelines do not exist. MethodsA retrospective, single-center, quality improvement audit was conducted on diabetic patients aged ≥18 years undergoing surgical procedures at the Townsville University Hospital, Australia, over a 12-week period. Perioperative outcomes were analyzed to establish compliance with the guidelines. Secondary objectives analyzed outcomes for Indigenous and non-Indigenous Australian patients, and patients’ age. Results202 patients were reviewed. 53 (26%) had preoperative blood glucose levels (BGLs) measured hourly. Of the patients requiring intraoperative BGLs, 93% did not have BGLs hourly and 71% did not have any intraoperative BGL. 23 (11%) had hourly BGLs postoperatively. Average preoperative haemoglobin A1c (HbA1c) was 7.5%, above target, and not measured in 45% of patients. 16/42 (38%) on metformin having major surgery had it restated appropriately. 29/41 (71%) on Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors did not have a perioperative ketone level measured. Categorizing subjects into American Society of Anesthesiologists (ASA) classes revealed a greater proportion of patients aged <60 years were of class II (34%) compared to patients aged 60–70 (16%) and >70 (15%) (p = 0.015). Indigenous patients were more likely to be younger than non-Indigenous patients, 59 compared to 68 (p<0.001), and have a higher preoperative BGL, 9.0 mmol/L (162 mg/dL) compared to 8.2 mmol/L (148 mg/dL) (p = 0.19). Conclusions: POMODA has displayed multiple areas for improvement in the perioperative management of diabetes. The authors recommend that pre-anaesthetic clinics for diabetic patients requiring surgery, particularly Indigenous Australians, be held at least two weeks prior to surgery to allow for optimisation of glycaemic control and clear perioperative instructions, and anticipate this being an important first step in improving guideline compliance.

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease

ObjectivesCompliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes. MethodsThe 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by the center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by the center. Our primary outcome was a composite end point of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid implementation document recommendations and associated outcomes were also assessed. ResultsOf the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38% to 95%, and median provider-specific compliance ranged from 36% to 100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, the use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing carotid endarterectomy for >70% asymptomatic stenosis (event rate in compliant vs noncompliant cases 0.59% vs 1.3%; adjusted odds ratio: 0.44, 95% confidence interval: 0.29-0.66); and second, carotid endarterectomy over transfemoral carotid artery stenting in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; adjusted odds ratio: 0.55, 95% confidence interval: 0.43-0.71). Of the 132 implementation document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67% to 100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with all 6 recommendations was associated with lower stroke/death. ConclusionsFew SVS recommendations could be assessed in the VQI because of incongruity between the recommendations and the VQI data variables collected. Although guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.

Is Education Alone Enough to Sustain Improvements of Antimicrobial Stewardship in General Practice in Australia? Results of an Intervention Follow-Up Study.

Sustained behaviour change and practice improvements for the optimal use of antimicrobials remains challenging in primary care. In 2018, a simple antimicrobial stewardship education programme involving guideline recommendations for common infections, antimicrobial audit reports, and local antibiograms resulted in significant improvements in guideline compliance and more appropriate antimicrobial prescribing by GPs. This observational follow-up study aims to examine the sustainability of the positive intervention effect after two years of implementation of the intervention. Practice-based data on all oral antimicrobial prescriptions issued by GPs were collected retrospectively to compare with intervention data and to measure the sustainability of the intervention effect. The data were analysed using a two-sample test of proportions. The primary outcomes included changes in the rate of prescription compliance with the Australian "Therapeutic Guidelines: Antibiotic" and the appropriateness of antimicrobial choice and duration of therapy. Overall, there was a significant decline in guideline compliance, from 58.5 to 36.5% (risk ratio (RR) (95% CI): 0.62 (0.52-0.74)), in the appropriateness of antimicrobial choice, from 92.8 to 72.8% (0.78 (0.73, 0.84)), and in the prescribed duration, from 87.7 to 53.3% (0.61 (0.54, 0.68)) in the intervention follow-up period. In respiratory infections and ear, nose, and throat infections, the rates of guideline compliance and appropriate choice and duration of antimicrobial prescription decreased significantly at p < 0.001. Appropriateness in the duration of antimicrobial therapy also significantly decreased for most antimicrobials. The evidence suggests that a simple and single-occasion antimicrobial stewardship education programme is probably not enough to sustain improvements in the optimal use of antimicrobials by GPs. Future research is needed to validate the results in multiple GP clinics and to examine the effect of sustained education programmes involving infection-specific and antimicrobial-targeted audits and feedback.

A retrospective study to identify the compliance with SDCEP guidelines of exodontia patients taking oral anticoagulant and antiplatelet medication

AbstractIntroductionExodontia treatment plans for oral anticoagulant and antiplatelet patients should consider Scottish Dental Clinical Effectiveness Programme (SDCEP) management guidelines. No previous literature has identified SDCEP guidelines compliance. The aim of this study was to determine how Oral Surgery staff manage exodontia patients who take antithrombotic medication, and the extent to which management principles consider SDCEP guidelines.Materials and MethodsAll clinical records were retrospectively analysed to identify patients who matched our criteria and had an exodontia procedure undertaken at Birmingham Dental Hospital over a 3‐month period.ResultsInitial records (n = 2961) of exodontia patients identified that 7.8% (n = 231) of patients were taking oral antithrombotic medication; 163 patients on Antiplatelet medication, 42 on Novel Oral Anticoagulants (NOAC) and 24 on Warfarin. No Antiplatelet or Warfarin patient had their medication regime interrupted. All Warfarin patients had their INR performed and recorded within 72 h of the procedure. A notable difference was found between managing high and low‐risk bleeding procedures for NOAC patients, although this was not statistically significant. Local intra‐operative haemostatic measures applied were significantly different between each of the drug groups (p &lt; 0.001). No local haemostatic measures were recorded in 45% of Antiplatelet patients, compared to 4.8% of NOAC and 12.5% of Warfarin cases. Self‐referrals are presented more commonly on a Thursday or Friday (p = 0.037).ConclusionsEach treatment plan should be considered on an individual basis, combining clinician expertise and clinical guidelines to optimise patient care. Areas of poor compliance were identified with further research being required to comprehend how compliance with the literature alters post‐operative haemostatic complications.

Impact of Institutional Prophylaxis Guidelines on Rates of Pediatric Venous Thromboembolism Following Trauma - a Multicenter Study from the Pediatric Trauma Society Research Committee.

A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population. A retrospective review of injured children (<15 years) admitted between 2009-2018 at ten pediatric trauma centers was performed. Data was gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using chi-square analysis (p < 0.05). 45,202 patients were evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Amongst critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the Guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study. The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data is needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma.Level IV, therapeutic/care management.

A bibliometric analysis of systematic reviews and meta-analyses in ophthalmology.

Bibliometric analysis is a quantitative method which applies mathematical and statistical tools to evaluate the inter-relationships and impacts of publications, authors, institutions and countries in a specific research area. Systematic reviews and meta-analyses (SRMAs) are summaries of the best available evidence to address a specific research question via comprehensively literature search, in-depth analysis and synthesis of results. To date, there have been several studies summarizing the publication trends of SRMAs in research specialties, however, none has conducted specifically in ophthalmology. The purpose of this study is to establish the scientometric landscape of SRMAs published in the field of ophthalmology over time. We retrieved relevant ophthalmological SRMAs and the corresponding bibliometric parameters during 2000 to 2020 from Web of Science Core Collection. Bibliometric analysis was performed using bibliometrix package. Pre-registration and guideline compliance of each article was independently assessed by two investigators. A total of 2,660 SRMAs were included, and the average annual growth rate was 21.26%. China and the United States were the most productive countries, while Singapore was the country with the highest average citations per document. Wong TY was not only the most productive, but also the most frequently cited author. The most productive affiliation was National University of Singapore (n = 236). Systematic reviews and meta-analyses output in most subspecialties had steadily increased with retina/vitreous (n = 986), glaucoma (n = 411) and cornea/external diseases (n = 303) constantly as the most dominant fields. Rates of pre-registration and guideline compliance had dramatically increased over time, with 20.0 and 63.5% of article being pre-registered and reported guideline in 2020, respectively. However, SRMAs published on ophthalmology journals tended to be less frequently pre-registered and guideline complied than those on non-ophthalmology journals (both p < 0.001). The annual output of SRMAs has been rapidly increasing over the past two decades. China and the United States were the most productive countries, whereas Singapore has the most prolific and influential scholar and institution. Raising awareness and implementation of SRMAs pre-registration and guideline compliance is still necessary to ensure quality, especially for ophthalmology journals.

Riding to health: Investigating the relationship between micromobility use and objective physical activity in Barcelona adults

BackgroundIn recent years there has been an increase in the use of micromobility devices in cities worldwide. Due to their novelty, their effects on population health are still unknown. In this study, we aim to explore the association between conventional and electric micromobility modes and daily physical activity levels in an adult population in the city of Barcelona. MethodsTracking data for 129 adults were collected in 2020 and 2021 as part of the NEWMOB project. Participants each wore an accelerometer and answered daily travel diaries for a week. Participants reported their daily use of micromobility devices through the travel log. Objective daily reports of physical activity levels were obtained from the accelerometer data. Statistical analysis explored the association between self-reported use of micromobility modes -shared bike, shared e-bike, e-scooter- and objective levels of physical activity. ResultsOn average, bike users, and users that combined different micromobility modes reported higher daily time spent in moderate-to-vigorous physical activity (MVPA) than other users. The lowest mean daily levels of MVPA were found among electric scooter users and non-micromobility users. In terms of light activity levels, the highest mean daily levels correspond to users of mixed modes and electric scooters. Analysing health guidelines compliance, bike users and mix modes users were the groups that more often met physical activity guidelines. ConclusionsMicromobility modes such as conventional and electric bikes can help to maintain high levels of MVPA, while meeting health guidelines, in contrast to e-scooters.

Call to action: overcoming enrollment disparities in cancer clinical trials with modernized eligibility criteria.

Traditional clinical trial eligibility criteria restrict study populations, perpetuating enrollment disparities. We aimed to assess implementation of modernized eligibility criteria guidelines among pancreatic cancer (PC) clinical trials. Interventional PC trials in the United States since January 1, 2014, were identified via clinicaltrials.gov with December 31, 2017, as the transition for pre- and postguidance eras. Trials were assessed for guideline compliance and compared using Fisher exact test. In total, 198 trials were identified: 86 (43.4%) were pre- and 112 (56.6%) postguidance era. Improvements were seen in allowing patients with history of HIV (8.6% vs 43.8%; P < .0001), prior cancer (57.0% vs 72.3%; P = .034), or concurrent and/or stable cancer (2.1% vs 31.1%; P < .0001) to participate. Most (>95%) trials were compliant with laboratory reference ranges, QT interval corrected for heart rate (QTc) cutoffs, and rationalizing excluding prior therapies both pre- and postguidance eras. However, overall compliance with modernized criteria remains poor. We advocate for stakeholders to update protocols and scrutinize traditionally restrictive eligibility criteria.

Perspective of People With Type 2 Diabetes Toward Self-management: Qualitative Study Based on Web Crawler Data.

The diabetes disease burden in China is heavy, and medical standards such as diabetes guidelines are the core reference guidelines for diabetes management for health care providers and patients. However, patients' guideline compliance is too low, which correlates with the gap between guidelines and patients' self-management needs. Incorporating patient needs into the guideline development would reduce this gap. We sought to capture the needs of patients with diabetes for self-management in everyday situations and to clarify the contradictions and misalignments between medical standards, such as guidelines, and patient needs. This study collected crawler-based data from 4 online health communities. We selected 1605 text records collected from Chinese patients with diabetes between March 2020 and July 2020 for analysis. The text analysis applied grounded theory to separate issues that concerned patients into 3 themes, 7 subthemes, and 25 entries. Altogether, 69.03% (1108/1605) of texts were related to issues concerning disease treatment (theme B) and mainly inquired about medication use (B2 and B3; 686/1108, 61.91%), including medication choice, change in medication administration, side effects, and postmedication effects. In addition, 222 (N=1605, 13.8%) texts (theme A) concerned the explanation of disease etiology and knowledge of diabetes, and 275 (N=1605, 17.1%) texts (theme C) discussed lifestyle changes and various restrictions on life brought about by the disease. Our findings suggest an urgent need to improve diabetes health education and guideline development strategies and to develop health management strategies from a patient perspective to bridge the misalignment between patient needs and current medical standards.

Guideline compliance and outcomes of genetic testing in pancreatic cancer patients.

688 Background: Guidelines recommend patients with pancreatic ductal adenocarcinoma (PDAC) undergo genetic testing for germline pathogenic variants (PV). The aim of this study was to evaluate compliance with recently updated guidelines (May 2019) and assess subsequent uptake and outcomes of genetic testing in PDAC patients. In addition, social and clinical factors associated with genetic testing were assessed. Methods: A retrospective chart review of patients diagnosed with PDAC between May 2018 and August 2020 was performed. Discussion and subsequent uptake of genetic testing was reviewed and compared between a 12-month period before (pre-guideline) and a 12-month period after (post-guideline) guidelines were updated, accounting for a three-month transition period. Univariate and multivariate logistic regression analysis was used to assess factors predictive of undergoing genetic testing. Results: In total, 534 patients with PDAC were identified; 321 (60.1%) in the pre-guideline period and 213 (39.9%) in the post-guideline period. The mean age at diagnosis was 68 years and 47% were female. Genetic testing was discussed in 34% (109/321) of pre-guideline and in 39% (84/213) of post-guideline patients ( P = .23). Of those, 82% (89/109) of patients in pre-guideline and 75% (63/84) in post-guideline groups underwent subsequent genetic testing ( P = .71). In 26 (17.1%) of 152 tested patients, a PV was identified, of which 17 (11.2%; 17/152) had a PDAC-associated PV. Age, cancer stage at diagnosis, length of survival, and having a first-degree relative with pancreatic cancer were significant predictors of genetic testing on multivariate analysis. Conclusions: Adherence to recently updated guidelines is poor and germline genetic testing in PDAC patients remains insufficient. Efforts to increase awareness of benefits of testing, which include personalized therapies for patients and cascade testing in family members for subsequent enrollment in pancreatic cancer surveillance programs, could improve future uptake.[Table: see text]

An Update on Test Use Evaluation of Serum Tryptase Levels

Guidelines recommend obtaining blood tryptase level within 15 minutes to 3 hours after onset of anaphylaxis or severe allergic reaction with follow up basal level at least 24 hours after resolution of anaphylaxis symptoms regardless of initial tryptase level. We seek to update our previously published abstract from 2010 in the Journal of Allergy and Clinical Immunology on guideline compliance.

Clinical practice selectively follows acute appendicitis guidelines

IntroductionAcute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.MethodsWe undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.ResultsFour thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1–4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).ConclusionsThe observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

Impact of antimicrobial stewardship interventions on days of therapy and guideline adherence: A comparative point-prevalence survey assessment

BackgroundAntimicrobial stewardship (AMS) is a crucial tool for rationalizing the use of antimicrobial agents and reducing the burden of antimicrobial resistance. We aimed to assess the impact of AMS interventions on antimicrobial utilization and adherence to antimicrobial guidelines.MethodsWe conducted a prospective quasi-experimental study at a major tertiary hospital in the United Arab Emirates. Using standardized World Health Organization’s methodology, point-prevalence surveys (PPS) were performed in November 2019 and January 2022. Core AMS interventions consisted of proactive bloodstream infection service, proactive and reactive infectious diseases consult service, prospective audit and feedback by clinical pharmacists, development of antimicrobial guidelines based on cumulative antibiograms, and implementation of induction programs for new clinical staff. Days of therapy (DOT) per 1000 patient days present and rate of compliance with antimicrobial guidelines were compared before and after the core interventions. Multiple logistic regression analysis was carried out to adjust for the potential confounding effects of age, gender, hospitalization within 90 days, central or peripheral line insertion, urinary catheterization, and mechanical ventilation. P-value&amp;lt;0.05 was considered statistically significant.ResultsPre- and post-intervention PPSs included 292 and 370 patients, respectively. Both had similar age and gender distribution. Patients receiving antimicrobials were 51% (149/292) in 2019 and 45% (166/370) in 2022 (p 0.12). Univariate analysis showed a reduced post-intervention DOT per 1000 patients present (6.1 +/- 16.2 vs 2.4 +/-5.1, p&amp;lt;0.01) and an improved post-intervention guideline compliance (59% vs 67%, p 0.23). Following multiple logistic regression, the reduction in post-intervention DOT remained statistically significant (co-efficient -0.17 (95% CI -8.58 to -1.94, p&amp;lt;0.01), and the improvement in guideline adherence became statistically significant (adjusted odds ratio 1.91 (95% CI 1.05 to 3.45, p 0.03).ConclusionCoordinated and sustained AMS interventions have a significant impact on improving antimicrobial utilisation and adherence to guidelines.

The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial.

Guidelines recommend against RBC transfusion in hemodynamically stable (HDS) children without cardiac disease, if hemoglobin is greater than or equal to 7 g/dL. We sought to assess the clinical and economic impact of compliance with RBC transfusion guidelines. A nonprespecified secondary analysis of noncardiac, HDS patients in the randomized trial Age of Blood in Children (NCT01977547) in PICUs. Costs analyzed included ICU stay and physician fees. Stabilized inverse propensity for treatment weighting was used to create a cohort balanced with respect to potential confounding variables. Weighted regression models were fit to evaluate outcomes based on guideline compliance. Fifty international tertiary care centers. Critically ill children 3 days to 16 years old transfused RBCs at less than or equal to 7 days of ICU admission. Six-hundred eighty-seven subjects who met eligibility criteria were included in the analysis. Initial RBC transfusions administered when hemoglobin was less than 7 g/dL were considered "compliant" or "non-compliant" if hemoglobin was greater than or equal to 7 g/dL. Frequency of new or progressive multiple organ system dysfunction (NPMODS), ICU survival, and associated costs. The hypothesis was formulated after data collection but exposure groups were masked until completion of planned analyses. Forty-nine percent of patients (338/687) received a noncompliant initial transfusion. Weighted cohorts were balanced with respect to confounding variables (absolute standardized differences < 0.1). No differences were noted in NPMODS frequency (relative risk, 0.86; 95% CI, 0.61-1.22; p = 0.4). Patients receiving compliant transfusions had more ICU-free days (mean difference, 1.73; 95% CI, 0.57-2.88; p = 0.003). Compliance reduced mean costs in ICU by $38,845 U.S. dollars per patient (95% CI, $65,048-$12,641). Deferring transfusion until hemoglobin is less than 7 g/dL is not associated with increased organ dysfunction in this population but is independently associated with increased likelihood of live ICU discharge and lower ICU costs.

Use of Clinical Decision Support to Improve the Laboratory Evaluation of Monoclonal Gammopathies

There is considerable variation in ordering practices for the initial laboratory evaluation of monoclonal gammopathies (MGs) despite clear society guidelines to include serum free light chain (sFLC) testing. We assessed the ability of a clinical decision support (CDS) alert to improve guideline compliance and analyzed its clinical impact. We designed and deployed a targeted CDS alert to educate and prompt providers to order an sFLC assay when ordering serum protein electrophoresis (SPEP) testing. The alert was highly effective at increasing the co-ordering of SPEP and sFLC testing. Preimplementation, 62.8% of all SPEP evaluations included sFLC testing, while nearly 90% of evaluations included an sFLC assay postimplementation. In patients with no prior sFLC testing, analysis of sFLC orders prompted by the alert led to the determination that 28.9% (800/2,769) of these patients had an abnormal κ/λ ratio. In 452 of these patients, the sFLC assay provided the only laboratory evidence of a monoclonal protein. Moreover, within this population, there were numerous instances of new diagnoses of multiple myeloma and other MGs. The CDS alert increased compliance with society guidelines and improved the diagnostic evaluation of patients with suspected MGs.