Standard Of Care Guidelines Research Articles

Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections

With the emergence and rising prevalence of methicillin-resistant Staphylococcus aureus among individuals in the community, it is imperative to standardize patient care and develop best practices among health care providers. Evidence-based standard patient care guidelines for community-acquired methicillin-resistant S aureus skin and soft tissue infections have the potential to positively impact patient outcomes, decrease health risk, reduce hospitalization from insufficient treatment, and decrease or even prevent further transmission to unaffected individuals. Emergency department providers are in a unique position to lead in the management and prevention of skin and soft tissue infections. It is essential that community-acquired methicillin-resistant S aureus skin and soft tissue infections are consistently treated by evidence-based treatment standards, especially with the growing number of pathogens displaying resistance to antibiotics, rising mortality, rapid spread of antimicrobial resistant microbes, and the escalating health care costs. The purpose of this literature review is to provide health care providers with current evidence-based health care guidelines for the treatment and management of community-acquired methicillin-resistant S aureus skin and soft tissue infections.

Lasers for vascular lesions: Standard guidelines of care

Lasers are a good therapeutic tool for congenital and acquired vascular lesions. Technological advances in lasers have reduced the adverse effects and increased the efficacy. MACHINES: Among the various lasers used for treating vascular lesions, pulsed dye laser (PDL) has the best efficacy and safety data. The other machines that are widely available are Nd:YAG laser and intense pulse light (IPL). RATIONALE AND SCOPE OF GUIDELINE: Much variation exists in different machines and techniques, and therefore, establishing standard guidelines has limitations. The guidelines recommended here indicate minimum standards of care for lasers on vascular lesions based on current evidence. Laser may be administered by a dermatologist, who has received adequate background training in lasers during post-graduation or later at a center that provides education and training in lasers, or in focused workshops, which provide such trainings. He/she should have adequate knowledge of the lesions being treated, machines, parameters, cooling systems, and aftercare. The procedure may be performed in the physician's minor procedure room with adequate laser safety measures. PWS, hemangioma, facial telangiectasia, rosacea, spider angioma, pyogenic granuloma, venous lakes, leg veins. Absolute: Active local infection, photo-aggravated skin diseases, and medical conditions. Relative: Unstable vitiligo, psoriasis, keloid and keloidal tendencies, patient on isotretinoin, patient who is not cooperative or has unrealistic expectation. Patient selection should be done after detailed counseling with respect to the course of lesions, different treatment options, possible results, cost, need for multiple treatments, and possible postoperative complications. TREATMENT SESSIONS: The number of treatments per lesion varies from 2 to 12 or more at 6-8 week intervals. All lesions may not clear completely even after multiple sessions in many cases. Hence, a realistic expectation and proper counseling is very important. Laser parameters vary with area, type of lesion, skin color, depth of the lesion, and machine used. A test spot may be performed to determine individual specifications. Pain, edema, purpura, bleeding, scarring, postinflammatory hyperpigmentation/hypopigmentation, and atrophy changes.

Standard guidelines of care: Keloids and hypertrophic scars

Keloids and hypertrophic scars (HTS) are the result of overgrowth of fibrous tissue, following healing of a cutaneous injury, and cause morbidity. There are several treatment modalities which are useful for the management of keloids, though no single modality is completely effective. The most commonly used modalities are pressure, silicone gel sheet, intralesional steroids, 5-fluorouracil (5 FU), cryotherapy, surgical excision, and lasers. They may be used either singly or, as is done more commonly, in combinations. Any qualified dermatologist who has attained postgraduate qualification in dermatology can treat keloids and HTS. Some procedures, such as cryosurgery and surgical excision, may require additional training in dermatologic surgery. Most modalities for keloids, including intralesional injections and mechanical therapies such as pressure and silicone gel based products, can be given/prescribed on OPD basis. Surgical excision requires a minor operation theater with the facility to handle emergencies. It is important to counsel the patient about the nature of the problem. One should realize that keloid will only improve and not disappear completely. Patients should be informed about the high recurrence rates. Different modalities carry risk of adverse effects and complications and the treating physician needs to be aware of these and patients should be informed about them.

Compliance with NICE guidelines in the management of self-harm

Aims and methodTo identify the provision of psychosocial assessments for all people attending an accident and emergency department in Ireland with a presentation indicative of self-harm over 12 months and to investigate whether the National Institute for Health and Clinical Excellence (NICE) guidelines for self-harm were met.ResultsA total of 834 attendances for self-harm were recorded. A psychosocial assessment was undertaken by a member of the liaison psychiatry team in 59% of attendances. Single male patients under 45 years of age represented 39% of those who did not receive a psychosocial assessment.Clinical implicationsSingle men under the age of 45 years represent a vulnerable group in which levels of psychosocial assessment need to be optimised in order to meet the NICE guidelines for standards of care.

Hyponatremia and Central Pontine Myelinolysis as a Result of Beer Potomania

Hyponatremia and Central Pontine Myelinolysis as a Result of Beer Potomania

Increased Adherence to Cardiac Standards of Care during Participation in Cardiac Disease Management Programs

Adherence to cardiovascular disease standards of care is critically important for minimizing the risk of mortality and morbidity for individuals with coronary heart disease (CHD) and heart failure (HF). The purpose of this study was to assess the ability of cardiac disease management (DM) programs to assist members with their adherence to evidence-based medicine for cardiovascular diseases. A total of 20,202 members with CHD and/or HF were evaluated 12 months prior to the start of DM programs and during their first 12 months of participation in the programs. Members were assessed for their adherence to appropriate cardiac medications. In addition, low-density lipoprotein (LDL) testing rates and clinical control of LDL values (defined as <100 mg/dL) were measured. The association between LDL control and use of lipid-lowering statins also was assessed. During participation in the cardiac programs, members achieved significant improvement in their adherence to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers (P < 0.0001). The cardiac population also achieved a significant increase in LDL testing rates and statin use (P < 0.0001). More members attained appropriate LDL control in year 1 compared to baseline (36% relative increase), and this improvement was associated with a 40% relative increase in statin use. In summary, participation in these cardiac DM programs assisted members to improve their adherence to cardiac medications and standards of care guidelines. Such improvements in cardiovascular disease care are likely associated with improved quality of life and reduced risk for mortality.

Tıbbi Uygulama Hatalarına Bağlı Mortalite ve Morbiditede Anestezinin Yeri

Anestezinin hatalı uygulanması iddiası ile hekimler ve diğer sağlık personeli aleyhlerine açılan davalarda ciddi bir artış gözlenmektedir. Perioperatif ölümlerle ilgili yapılan retrospektif çalışmalar ölüm nedenlerinin büyük çoğunluğunun kişinin preoperatif hastalığına ve cerrahi girişime bağlı olduğunu göstermektedir. Bununla beraber anestezi uygulamasma bağlı ortaya çıkan istenmeyen durumlarında en büyük sebebini insan hataları oluşturmaktadır. Büyük çoğunluğu önlenebilir anestezi kazalarına bağlı gelişen tıbbi uygulama hatalarının en aza indirilmesi için standart monitorizasyon uygulaması, sürekli eğitim, çalışma koşularının iyileştirilmesi, dava konusu tıbbi uygulama konularmda geri bildirim, anestezi uygulaması ve kriz yönetimini içeren standart bakım rehberlerinin geliştirilmesi çok önemlidir.Anahtar kelimeler: Anestezi, tıbbi uygulama hatası

General anaesthesia for dentistry

Although general anaesthesia is used to reduce the pain and anxiety associated with dental treatment, most dental procedures can be managed with good local anaesthesia, with or without conscious sedation. Since the 1960s there has been a progressive fall in the use of general anaesthesia for dentistry and in the mortality associated with it. However, between 1996 and 1999, eight people died as a result of dental anaesthesia, five of them were children. Investigations and inquiries into these deaths were critical of the standard of care provided in areas such as preoperative assessment, perioperative monitoring, resuscitation and transfer to a critical care facility. In response to these concerns, the General Dental Council (GDC), the Royal College of Anaesthetists (RCA) and the Department of Health (DOH) have issued closely linked guidelines for standards of care in dental general anaesthesia. Since 1 January 2002, general anaesthesia for dentistry has been confined to a hospital setting with critical care facilities. This article summarizes the guidelines, with particular reference to the status of the anaesthetist, the indications for general anaesthesia, patient referral and assessment, the definition of a hospital setting, peroperative monitoring and resuscitation, and management of the emergency; it also reviews the technique of dental anaesthesia in current use.

Chronic Blood Transfusion Therapy Practices to Treat Strokes in Children with Sickle Cell Disease

To identify variations in practices used by nurses for pediatric patients with sickle cell disease (SCD) receiving chronic blood transfusion therapy for strokes. Descriptive study of a convenience sample of 11 nurses who care for children with SCD from nine institutions completed a closed-ended questionnaire consisting of 37 items. Responses reflected practice experience with a total of 189 transfused patients with SCD. A wide range of nursing practices exists for blood transfusion therapy for children with SCD and strokes. Manual partial exchange transfusion (66%) was the most commonly used method for blood transfusion in children with strokes reported among the nurses surveyed. Simple transfusions and erythrocytapheresis account for 21% and 13% of the practices reported. Opportunities exist to establish evidence-based nursing care guidelines to improve the care of children with strokes receiving blood transfusion therapy. A wide range of local standard care guidelines for blood transfusion therapy exists. The results of this survey indicate that partial manual exchange transfusion is the most commonly used method of chronic blood transfusion therapy in children with SCD and stroke despite the fact that the magnitude of benefit in comparison with simple transfusion has not been established. Factors such as peripheral venous access, compliance with current chelation regimen, and the presence of antibodies are important considerations in the choice of method.

A clinical audit of the quality of care of hypertension in general practice

Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from "best practice" can then be examined, and causes can be determined and acted upon. The Ministry of Health (MOH), Jamaica, has recently published standards of care for hypertension. The medical records of a convenience sample of 125 hypertensive patients being managed by five current family medicine residents in their respective primary care practices were audited Initial results showed limited adherence to the MOH recommended hypertension management guidelines. The same practices were re-audited after an interval of six months, during which time the physicians were sensitized to the results of the preliminary audit. Marked improvements were noted in the second audit. Assessment for co-risk factors for hypertension-related diseases improved: nutritional advice (33% to 74%), smoking and alcohol intake history (40% to 65%) and history taking of physical activity (30% to 47%). Assessment for target organ damage also improved: fundoscopy done (11% to 54%), foot examination done (30% to 58%) and yearly electrolytes done (28% to 62%). There are clear gaps between current practice and standards that exist internationally and locally for management of hypertension. The MOH needs to disseminate and educate general practitioners about the standards of care guidelines.

Outcomes from pediatric solid organ injury: role of standardized care guidelines

Recent advances in the delivery of trauma and critical care in children have resulted in improved outcome following major injuries. It is imperative that physicians who treat injured children familiarize themselves with current treatment algorithms for abdominal trauma. Important contributions have been made in the diagnosis and treatment of children with abdominal injury by radiologists and endoscopists. This report examines the impact of consensus guidelines in the treatment of blunt abdominal solid organ injuries. Consensus guidelines for treatment of children with isolated spleen and liver injury are reviewed demonstrating conformity of care and significant reduction of resource utilization without adverse sequelae. Review of large datasets indicate contrasting rates of splenectomy depending on the expertise of the institution, emphasizing the need for wide dissemination of guidelines. Clinical experience and published reports addressing specific concerns about the nonoperative treatment of children with solid organ injuries and recent radiologic and endoscopic contributions have made pediatric trauma care increasingly nonoperative. Although the trend is in this direction, the pediatric surgeon should remain the physician-of-record in the multidisciplinary care of critically injured children.

Angiographic assessment of cerebral circulation time for outcome prediction in patients with subarachnoid hemorrhage

Background In the acute stage following subarachnoid hemorrhage (SAH), prolonged cerebral circulation time reflects increased intracranial pressure (ICP), which can lead to irreversible brain damage. We evaluated the ability of cerebral circulation time to predict outcome in SAH patients. Methods We prospectively studied 40 consecutive patients treated for SAH according to standard intensive care guidelines. Lateral views in preoperative carotid digital subtraction arteriograms (DSA) were used to determine arteriovenous transit time (AVTT), defined as interval from initial opacification of the intracranial internal carotid artery to that of the Rolandic vein. We then analyzed relationship of AVTT to other prognostic parameters and outcome. Results AVTT depended on initial Glasgow Coma Scale score (GCS), ranging from 3.4 to 8.0 seconds (mean: 5.4) when initial GCS was 13 to 15; from 4.5 to 8.7 seconds (mean: 6.4) when initial GCS was 7 to 12; and from 5.8 to 15.0 seconds (mean: 9.1 seconds, excluding angiograms with nonfilling) when initial GCS was 3 to 6. AVTT correlated significantly with prognosis, longer AVTT predicting poorer outcome. No patient with an AVTT above 12 seconds recovered to a functioning state. Conclusions AVTT obtained from routinely performed acute-phase DSA in SAH patients reflects ICP and functional prognosis, representing a cost-effective, practical, and reliable outcome predictor.

Emergency department triage of patients with acute chest pain: definition of cardiac troponin I decisional value to manage patients without electrocardiographic evidence of ischemia.

The aim of this study was to define the use of a new cardiac troponin I (cTnI) assay for emergency patients with chest pain and no specific electrocardiographic changes consistent with the presence of ischemia. Patients (n = 106) admitted in Emergency/Cardiology Departments for chest pain and suspicion of acute coronary syndrome (ACS) were randomized into two diagnosis groups (ACS or non-ACS) by two independent cardiologists. cTnI measurements were performed at admission, and 6 hours and 12 hours later with a new generation assay (Access AccuTnI, Beckman Coulter). Using an upper reference limit of 0.04 microg/l, 27 patients had a cTnI elevation not related to the final diagnosis of ischemia; the positive predictive value (PPV) was 67% with specificity 48%. The decisional value was re-defined and set at 0.16 microg/l, a concentration corresponding to the 99th percentile of the non-ACS patient group. Precision (coefficient of variation) was 8% at this level, PPV 97% and specificity 98%. This new decisional value is now used in our institution and could be included in standard care guidelines to improve the management of patients presenting chest pain in emergency departments.

Intermittent prone positioning improves oxygenation but has no influence on outcome in the treatment of post-traumatic lung injury: a prospective, randomized, controlled study

In a randomized trial the effect of a predefined strategy of prone positioning on the duration of mechanical ventilation was evaluated in multiple trauma patients with acute lung injury or acute respiratory distress syndrome. Patients in the prone group (n = 21) were continuously kept prone for at least 8 hours and a maximum of 24 hours per day. Prone positioning was continued until a PaO2:FiO2 ratio of more than 300 was present in the prone as well as the supine position over a period of 48 hours. Patients in the supine group (n = 19) were positioned according to standard care guidelines. The duration of ventilatory support did not differ significantly between the two groups (20 ± 17 days in the prone group and 33 ± 23 days in the supine group). The mean duration of ventilatory support in prone position was 11 ± 5 hours a day. A mean of 7 ± 4 posture changes was applied per patient. One patient in the prone group and three patients in the supine group died due to multiorgan failure (P = 0.33). The PaO2:FiO2 ratio increased significantly more in the prone group than in the supine group in the first 4 days (P = 0.03). Thereafter no significant difference in the PaO2:FiO2 ratio was evident between the two groups. The number of adverse effects was not different between the groups. Therefore, despite an improvement of gas exchange, no clinical outcome benefit was detected.

The Henry Ford Health System.

The Henry Ford Health System is a large, vertically integrated health care delivery system, with its core service delivery team comprised of a 1000-person salaried medical group. Oncology services are coordinated through its Cancer Center, which organizes regional distribution of oncology services for residents of southeast Michigan. Oncology services are delivered through five regionally distributed sites, affording a vast majority of cancer services to be provided for patients a short distance from their homes. The System owns the largest health maintenance organization in Michigan (Health Alliance Plan) and its organizational structure affords the opportunity of offering purchasers specific oncology service contracting opportunities. Advantages of providing comprehensive oncology services through an integrated health system include: 1) standardized cancer care guidelines, 2) medical information exchange through an electronic medical record, 3) interdisciplinary cancer care provided by salaried physicians, minimizing potentially conflicting financial issues in treatment decisions, 4) state-of-the-art care afforded through availability of involvement in a large number of National Institutes of Health-sponsored clinical trials, 5) high standards of credentialing for oncology physicians, and 6) integrative managed care perspectives and continuous attention to cost and quality of care issues.

Decision support in healthcare

To address the recognized problems associated with information overload and limited human memory, computer-based systems which help healthcare providers use information to make better decisions have been developed and implemented. These decision aids are designed to improve the quality and reduce the cost of healthcare. Currently, the most widely used computer application is to simply provide needed facts about the patient in an organized and timely fashion. Additionally, healthcare workers can access literature, ask questions of aggregates of patient data for clinical or administrative decisions, receive warnings or suggestions when the patient's data satisfy certain logical rules receive critiques when proposing therapies or ordering diagnostic tests, receive guidelines for standards of care, access programs which analyze tradeoffs and likelihoods of alternative outcomes (decision analysis) and receive lists of differential diagnoses. Given this wonderful panoply of capabilities, the question becomes 'why aren't more people using these aids and what are the demonstrated benefits of such capabilities?' In this paper we review the types of decision aids which have been successfully implemented and the challenges to implementation (knowledge representation, connections to databases, need for comprehensive, coded databases and evaluation of benefits).

Guidelines for standards of care for patients with acute respiratory failure on mechanical ventilatory support

Guidelines for standards of care for patients with acute respiratory failure on mechanical ventilatory support