Implementation Of New Guidelines Research Articles

Improving neonatal resuscitation in Tennessee: a large-scale, quality improvement project.

We report a statewide collaborative quality initiative to improve resuscitation and stabilization practices following introduction of the 6th edition of the Neonatal Resuscitation Program. Participants drafted a consensus toolkit of interventions and corresponding measures. Hospital teams collected baseline data, and implemented changes using PDSA-cycles and statistical process control charts. Nine Tennessee NICUs submitted data on 3771 resuscitations. "Special cause" improvements were achieved and sustained for pre-resuscitation checklists (77-90%) and team briefings (80-92%). Time to intravenous access (50-42 min), glucose infusion initiation (73-60 min), and antibiotic dosing (113-98 min) were also significantly reduced. Teams were unable to meet new NRP oxygen saturation targets. Improvements in post-resuscitation debriefing were not sustained, while communication with parents declined significantly (68-60%). Large-scale collaboration facilitated statewide implementation of new guidelines, while highlighting under-appreciated systems challenges among competing resource demands.

Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain.

The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.

Tackling Cancer Associated Thrombosis: A Multi-Professional Approach

Abstract Introduction Thromboembolism is a leading cause of death in people with cancer; second only to the cancer itself. There is an urgent need to raise the profile of cancer associated thrombosis amongst not only patients but staff treating people with cancer. Aims This project aimed to educate cancer patients about their thrombotic risk and to improve both the prevention and treatment of cancer associated thrombosis. Methods A review of attitudes and use of thromboprophylaxis was performed in a large, UK-based, teaching hospital; prior to and following the introduction of a new strategy to improve knowledge of cancer associated thrombosis. The study was performed between March and July 2018, with the strategy fully implemented by May 2018. This strategy included a three pronged approach: the introduction of a regular teaching programme for nurses, pharmacists and doctors; the implementation of new guidelines relating to cancer associated thrombosis; and the use of educational videos and posters within patient areas. The knowledge of clots/thrombosis of people with cancer, discussions with staff concerning thrombotic risk and use of tinzaparin thromboprophylaxis at a high risk dose (4500 units) were all investigated. Cancer patients admitted to the hospital were eligible for the study only if they had been admitted for at least 24 hours, this allowed staff the opportunity to discuss the risk of thrombosis with them. A typical one week period was chosen to complete each part of the study, the second week occurred two months after the introduction of the new strategy. A p value of <0.05 was considered significant and was calculated using a Chi-square test. Results A total of 91 patients were included in the study (42 prior to the intervention and 49 following). They included a mix of both out-patients (32/42, 74% prior to intervention and 25/49, 51% following) and in-patients (10/42, 26% prior to and 24/49, 49% following). Median age was 65 years (range 21 - 87 years) prior to intervention and 67 years (range 21 - 86 years) following. For those admitted to hospital, the median length of admission was 3 days (range 1-84 days) prior to intervention and 4 days (range 2-33 days) following. Overall there was a slight male preponderance (55% both prior to intervention and following). People with a range of cancer types were interviewed. In the cohort prior to intervention the most common cancer sites were: lung (8/42), bowel (8/42) and skin (7/42). Following the intervention the most common were: breast (6/49), skin (5/49) and lung (4/49). A higher proportion of people questioned before the intervention had known metastases (29/42, 69% prior to and 22/49, 45% following; p<0.05). Generally people with cancer had a good knowledge of venous thromboembolism and this remained high following the intervention (39/42, 93% to 41/49, 84%; p=0.18). There was a significant increase in the number of people who had discussed thrombotic risk with a healthcare professional during their hospital admission or out-patient treatment (12/42, 24% to 24/49, 51%; p<0.05). The use of tinzaparin thromboprophylaxis in those eligible to receive it, remained high following the intervention (13/16, 81% to 16/17, 91%, p=0.26) and the appropriate use of a higher risk dose (4500 units) rose significantly (1/13, 8% to 12/16, 75%, p<0.001). Conclusion The use of a multi-professional approach to preventing and treating cancer associated thrombosis increased discussion between staff and patients regarding thrombosis and improved accuracy of thromboprophylaxis dosing. Our results strongly support the use of a strategy based on regular training and patient education. Disclosures Gabriel: Leo Pharma: Other: Travel and accommodation sponsorship. Musgrave:Leo Pharma: Other: Travel and accomodation sponsorship.

Adherence to ATA 2015 guidelines in the management of unifocal non-invasive papillary thyroid cancer: a clinical survey among endocrinologists and surgeons.

Despite updated guidelines, management of thyroid nodules remains controversial. We aim to check implementation of new guidelines by ear-nose-throat (ENT) surgeons and endocrinologists. A questionnaire was e-mailed including demographic data and an index case: a healthy 26-year-old women with a 3-cm Bethesda III (B3) atypia of undetermined significance solitary nodule and eventually papillary thyroid cancer (PTC). Respondent rate was 50.5%, 93 endocrinologists, 55 surgeons. For this case, 77.4% would repeat fine-needle aspiration (FNA), 25.3% order molecular analysis and 22.6% do surgery. If repeated FNA remained B3, 51% would choose surgery, 17.3% molecular analysis and 31.6% follow-up only. If repeated FNA was B6, 58.5% would recommend total (TTx) and 41.5% hemithyroidectomy (HTx). In pathologically confirmed PTC after HTx, 42.4% would recommend completion, 26.8% radioactive iodine (RAI) treatment. For a > = 4-cm tumor, 49.2% would recommend TTx. For a tumor 2-4cm, 41% would recommend TTx. Variables favoring TTx were family history and radiation exposure. Only 17.4% would prefer TTx when small benign contralateral tumor is present. Reassessment at 1year with undetectable thyroglobulin (Tg) included stimulated Tg (stTg) (72.5%), neck US only (27.5%) and combined US-stTg (59.4%); only 10.3% would order a diagnostic scan. For recurrence in two (13-9mm) lymph nodes, 59.3% recommend reoperation, 16.3% RAI and 24.4% active surveillance. There were no major differences between endocrinologists and ENT surgeons. We report a considerable lack of adherence to new guidelines, with only 50% recommending HTx for a 4-cm unifocal low-risk PTC tumor.

Improving the Quality of MRI Reports of Preoperative Patients With Rectal Cancer: Effect of National Guidelines and Structured Reporting.

Since the implementation of new guidelines for rectal cancer in The Netherlands in April 2014, clinical stage as seen at preoperative MRI indicates whether neoadjuvant therapy is necessary before rectal cancer surgery. Therefore, the importance of correct MRI interpretation has increased. The aim of this study was to evaluate the completeness of MRI reports of rectal cancer and the effect of implementation of the new guidelines and standardized reporting on the completeness of these reports. Data were collected from all patients who consecutively underwent rectal cancer surgery at one hospital between January 2011 and July 2017. Data were extracted from electronic patient records. The study included 492 MRI examinations. Before implementation of the new guidelines, a median of 4 of 10 items (interquartile range [IQR], 3-6 items) were described in each MRI report. After implementation of the new guidelines, the number of items described improved significantly (median, 7 items; IQR, 6-8 items; p < 0.001). Implementation of a standardized report led to further significant improvement (median, 9 items; IQR, 9-10 items; p < 0.001). The items scored most frequently were distance between the tumor and the anal verge (85.6%) and length of the tumor (87.6%). The items scored least were presence or absence of extramural venous invasion (21.1%) and morphologic features of the tumor (24.6%). Implementation of a standardized protocol and a standardized reporting system for MRI in preoperative staging of rectal cancer results in a more complete MRI report.

Reducing Blood Glucose Testing Is Safe in Patients Receiving Parenteral Nutrition.

Hyperglycemia is a common adverse event associated with parenteral nutrition (PN); however, there is no consensus on optimal glucose monitoring. Unnecessary point-of-care (POC) blood glucose (BG) testing can result in additional healthcare cost and discomfort to the patient. This study's aim was to determine whether decreasing the frequency of POC glucose testing in patients receiving PN can reduce costs without increasing the frequency of glycemic events. This study examined adult, noncritically ill patients who require PN and are managed by a nutrition support team. Guidelines were developed for the initiation and discontinuation of POC BG monitoring. Pre-intervention and post-intervention data were collected for each patient, including daily POC glucose and glucose from the basic metabolic panel (BMP). Equivalency testing was completed for each group. Data were collected on 171 subjects (86 preguideline, 85 postguideline). The total number of POC tests per patient was significantly less in the postintervention period (median 23.0 vs 25.5; P = .011), as well as the average number of POC tests per patient per day (2.9 ± 1.4 vs 3.6 ± 1.4; P < .001). The average BMP glucose (126 mg/dL preintervention vs 129 mg/dL postintervention; P = .005) and the number of hypoglycemic and hyperglycemic events per 100 tests (both P < .001) were equivalent. Implementation of new guidelines resulted in decreased frequency of POC BG tests by 20%, which may impact cost savings and patient comfort in hospitalized patients receiving PN without increasing average BG level or glycemic events.

Acting on audit & feedback: a qualitative instrumental case study in mental health services in Norway

BackgroundThe National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders, launched in 2012, is to be implemented in mental health services in Norway. Audit and feedback (A&F) is commonly used as the starting point of an implementation process. It aims to measure the research-practice gap, but its effect varies greatly. Less is known of how audit and feedback is used in natural settings. The aim of this study was to describe and investigate what is discussed and thematised when Quality Improvement (QI) teams in a District Psychiatric Centre (DPC) work to complete an action form as part of an A&F cycle in 2014.MethodsThis was an instrumental multiple case study involving four units in a DPC in Norway. We used open non-participant observation of QI team meetings in their natural setting, a total of seven teams and eleven meetings.ResultsThe discussions provided health professionals with insight into their own and their colleagues’ practices. They revealed insufficient knowledge of substance-related disorders and experienced unclear role expectations. We found differences in how professional groups sought answers to questions of clinical practice and that they were concerned about whether new tasks fitted in with their routine ways of working.ConclusionActing on A&F provided an opportunity to discuss practice in general, enhancing awareness of good practice. There was a general need for arenas to relate to practice and QI team meetings after A&F may well be a suitable arena for this. Self-assessment audits seem valuable, particular in areas where no benchmarked data exists, and there is a demand for implementation of new guidelines that might change routines and develop new roles. QI teams could benefit from having a unit leader present at meetings. Nurses and social educators and others turn to psychiatrists or psychologists for answers to clinical and organisational questions beyond guidelines, and show less confidence or routine in seeking research-based information. There is a general need to emphasise training in evidence-based practice and information seeking behaviour for all professional groups.

The Health Belief Model and Preventive Measures: A Study of the Ministry of Health Campaign on Coronavirus in Saudi Arabia

As of August 2017, approximately 684 people have died in the Kingdom of Saudi Arabia since the coronavirus Middle East respiratory syndrome (MERS-CoV) outbreak in 2012. Saudi Arabia became the leading country for the number of illnesses and deaths related to MERS-CoV, making this a health megacrisis. Early Ministry of Health (MOH) communication efforts proved ineffective and created anger, confusion, and mistrust. Changes in command, implementation of new guidelines and policies, and a health preventive campaign have been instrumental in the fight. The MOH launched the “We Can Stop It” campaign in 2015. This study shares results from a survey of 875 students from King Saud University on the credibility of MOH information and effectiveness of the campaign’s prevention recommendations. Results show that the MOH is a credible source of information and that Saudis are following most, but not all, recommended preventive measures. Those persons with higher perceived benefits and lower barriers are more likely to follow recommended guidelines.

The antibiotic management of gonorrhoea in Ontario, Canada following multiple changes in guidelines: an interrupted time-series analysis

ObjectiveThis study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance.MethodsWe used interrupted times-series analyses to analyse treatment data for cases...

Anticoagulation therapy in elderly patients with atrial fibrillation: results from the Registry of Atrial Fibrillation To Investigate the Implementation of New Guidelines (RAFTING).

Patients with atrial fibrillation aged 75 years or older have a CHA2DS2VASc score that dictates oral anticoagulants. We recorded physicians' anticoagulation attitudes in elderly patients with atrial fibrillation and assessed the impact of stroke and bleeding risk. Atrial Fibrillation To Investigate the Implementation of New Guidelines , a countrywide prospective registry performed in Greece during 2010, a period when only vitamin-K antagonists (VKA) were available, enrolled 1127 patients with atrial fibrillation diagnosis during Emergency Departments visit in 31 representative hospitals; 807 patients had known atrial fibrillation and of those, 342 aged 75 years or older. We recorded preadmission anticoagulation treatment and associated it with clinical characteristics and stroke/bleeding risk. Patients on VKA (n = 207; 61%) were younger (81 ± 4 vs. 83 ± 5; P < 0.001) but no other significant differences were noticed, including mean CHA2DS2VASc (high: 2-4, very high: >4) or modified HASBLED (low: 0-2, high: >2) scores. VKA were prescribed in 65% of patients with very high CHA2DS2VASc score as compared with 55% of those with high score (P = 0.065). VKA were used equally in low or high-modified HASBLED score (61% vs. 59%; P = 0.78). The interaction between CHA2DS2VASc and HASBLED was significant (P < 0.001) in patients on VKA; in patients with low HASBLED, VKA use was similar in high versus very high CHA2DS2VASc score (58 vs. 64%), whereas in patients with high HASBLED, VKA use tended to be higher in very high versus high CHA2DS2VASc score (66 vs. 43%). In this countrywide atrial fibrillation registry, 61% of elderly patients received VKA, a decision driven mainly by stroke risk. VKA use was not higher in patients with low bleeding risk.

Impact of the Implementation of New WHO Diagnostic Criteria for Gestational Diabetes Mellitus on Prevalence and Perinatal Outcomes: A Population-Based Study.

Objectives. To determine the impact of the implementation of new WHO diagnostic criteria for gestational diabetes mellitus (GDM) on prevalence, predictors, and perinatal outcomes in Croatian population. Methods. A cross-sectional study was performed using data from medical birth certificates collected in 2010 and 2014. Data collected include age, height, and weight before and at the end of pregnancy, while perinatal outcome was assessed by onset of labor, mode of delivery, and Apgar score. Results. A total of 81.748 deliveries and 83.198 newborns were analysed. Prevalence of GDM increased from 2.2% in 2010 to 4.7% in 2014. GDM was a significant predictor of low Apgar score (OR 1.656), labor induction (OR 2.068), and caesarean section (OR 1.567) in 2010, while in 2014 GD was predictive for labor induction (OR 1.715) and caesarean section (OR 1.458) only. Age was predictive for labor induction only in 2014 and for caesarean section in both years, while BMI before pregnancy was predictive for all observed perinatal outcomes in both years. Conclusions. Despite implementation of new guidelines, GDM remains burdened with increased risk of labor induction and caesarean section, but no longer with low Apgar score, while BMI remains an important predictor for all three perinatal outcomes.

Prospective surveillance of daptomycin and intravenous colistin use after implementation of new guidelines

Introduction Antimicrobial restriction is an effective strategy to control antibiotic use and limit the spread of bacterial resistance [1] , [2] . Due to the progressive increase in daptomycin and intravenous colistin use in our hospital, local guidelines were implemented in 2013. Objective We aimed to evaluate the appropriateness of daptomycin and intravenous colistin prescriptions according to new guidelines. Method We performed a prospective observational study by reviewing all prescriptions of daptomycin (09/2013–01/2015) and intravenous colistin (01/2014–01/2015). We used specific order forms received at the pharmacy to identify prescriptions. Clinical and bacteriological data were retrieved from patients’ electronic charts. Antimicrobial appropriateness was appraised according to guidelines: accepted indications and dosage for both antibiotics, follow up of creatine kinase (CK) levels for daptomycin and use in combination therapy for intravenous colistin. Results In total, 25 daptomycin and 18 intravenous colistin prescriptions were evaluated. Of the 25 daptomycin prescriptions, 21(84%) met the accepted indications: 10 cases planned for outpatient parenteral antibiotic therapy (OPAT), 7 cases of severe allergy to vancomycin, 2 MRSA bacteremia/endocarditis not responding to vancomycin, 2 vancomycin-induced nephrotoxicity. Two (8%) prescriptions did not meet accepted indications but were nevertheless considered justified. Only 2 (8%) prescriptions were considered unjustified. Dosage was adequate in 92% of patients and CK levels were followed up in 88%. Orders were validated by infectious diseases (ID) specialists in 92% of cases. Of the 18 intravenous colistin prescriptions, 17 (95%) met the accepted indications. 12/18 (63%) dosages were adequate; 6 (32%) were not because of lack of loading dose in cystic fibrosis patients or lack of adaptation to renal function. Another antibiotic was associated in 100% of cases. Orders were validated by ID specialists in 8/18 cases (44%). Discussion This prospective surveillance allowed us to observe that the appropriateness of prescriptions of 2 restricted antibiotics was satisfactory. Dosages for intravenous colistin in cystic fibrosis patients will be reevaluated. The collaboration between the pharmacy and the antibiotic stewardship team is needed as the number of restricted antibiotics tends to increase.

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences.

BackgroundHypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.MethodsA phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.ResultsThe majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.ConclusionsThis study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

A taxonomy for education and training in professional psychology health service specialties: Evolution and implementation of new guidelines for a common language.

The Education and Training Guidelines: A Taxonomy for Education and Training in Professional Psychology Health Service Specialties was endorsed as a policy of the American Psychological Association in 2012. These Guidelines have the potential for broad impact on the field by providing both a structure and recommendations for the consistent usage of language--definitions and terminology--to reduce current descriptive inconsistencies across education and training programs in professional psychology. The Guidelines are not designed to define specifics of the training or practice of individual psychologists; they are to be used only to describe programmatic structure in a consistent manner. This article details the developmental history of these Guidelines and highlights the strong alliance between the leaders of the various recognized specialties in professional psychology and the education and training community in health service psychology. The content, application, future dissemination and impact of the Guidelines are presented.

Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years.

BackgroundIn 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation.Methods and FindingsWe compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009–2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2–10<5%), moderate (PfPR2–10 5–40%), high (PfPR2–10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%–21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56–0.69) and community health workers (OR: 0.31, 95% CI: 0.23–0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42–0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39–1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16–1.54).ConclusionsDiagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.

(Re)Programming Europe: European Capitals of Culture: rethinking the role of culture

Celebrating the 25th anniversary of the European Capital of Culture (ECoC) programme in 2010 as a success story for the cities and member states involved, the European Commission also registered a ‘lack of Europe’ in the programme. This is reflected in the scholarly literature, which has largely focused on the title’s effects on individual cities rather than on its effects on Europe. The starting-point of this article is the demand of the European Commission for a stricter implementation of new guidelines developed since 2006 for enhancing the European dimension. After situating the history of the event and its idea of ‘unity in diversity’ within the wider context of thoughts on Europe as an ‘imagined community’, this article investigates how Europe is presented in earlier and more recent ECoC bidbooks and programmes. We argue that an observed slight shift in the programme’s content, from a competition-based marketing of local identity towards a more universal value discourse, could be read as a first step towards (re)formulating the European dimension. We suggest that this emerging value paradigm also illustrates how such cultural programmes as a kind of laboratory could contribute to a conceptual reflection on (and beyond) Europe.

Missed Opportunities Among HIV-Positive Women to Control Viral Replication During Pregnancy and to Have a Vaginal Delivery

Most national guidelines for the prevention of mother-to-child transmission of HIV in Europe updated between 2001 and 2010 recommend vaginal deliveries for women with undetectable or very low viral load (VL). Our aim was to explore the impact of these new guidelines on the rates of vaginal deliveries among HIV-positive women in Europe. In a pooled analysis of data on HIV-positive pregnant women enrolled in the Swiss Mother & Child HIV Cohort Study and the European Collaborative Study 2000 to 2010, deliveries were classified as occurring pre- or postpublication of national guidelines recommending vaginal delivery. Overall, 2663 women with 3013 deliveries were included from 10 countries; 28% women were diagnosed with HIV during pregnancy. Combination antiretroviral therapy was used in most pregnancies (2020, 73%), starting during the first or second trimester in 78% and during the third trimester in 22%; in 25% pregnancies, the woman conceived on combination antiretroviral therapy. Overall, in 86% pregnancies, a VL < 400 copies per milliliter was achieved before delivery. The proportion of vaginal deliveries increased from 17% (414/2377) before the change in guidelines to 52% (313/600) after; elective Caesarean section rates decreased from 65% to 27%. The proportion of women with undetectable VL having a Caesarean section was 55% after implementation of new guidelines. We observed a decrease of late preterm deliveries from 16% (377/2354) before to 7% (42/599) after the change in guidelines (P < 0.001). There are still missed opportunities for women with HIV to fully suppress their VL and to deliver vaginally in Europe.

P6.014 Kenya’s Progress Towards Elimination of Mother-To-Child Transmission (EMTCT) of HIV

<h3>Background</h3> According to Kenya’s Demographic Health Survey (KDHS) 2009, 6.2% of 39 million residents are HIV-infected. Of 1.5 million annual pregnancies, 93,000 are HIV-infected. Without interventions, 35–40% of their infants would be infected. We describe Kenya’s progress towards eMTCT. <h3>Methods</h3> Kenya has Prevention of MTCT Technical Working Group with members from Ministry of Health, PEPFAR agencies, UN family, implementing partners focusing on guideline and policy development. From single dose nevirapine in 2005 to Option A in 2010, Kenya is rolling out new guidelines with Option B+, elimination framework, mentor mother programmes, health systems strengthening activities, community strategies, private partnerships, and maternal/child health integration of anti-retroviral (ARV) therapy. Appointment diaries, mobile telephones, home visits are retention strategies. Longitudinal antenatal registers, mother-baby booklet, HIV-Exposed Infant (HEI) registers for easy identification and tracking of mothers and infants used. HEI are identified and tested at 6–8 weeks through PCR. Capacity building, infrastructure, supportive supervision, commodity security, safe infant feeding are monitored. EID dashboard (website) shows EID results from all PCR labs in real-time. <h3>Results</h3> Kenya demonstrates tremendous progress from 2005 to 2012: PMTCT sites from 926 to 4,500; pregnant women counselled and tested for HIV from 318,000 to 1.2 million (80% coverage); ARV prophylaxis from 52% to 90% of HIV-positives identified; CD4 access from &lt; 50% to &gt; 72%; over 57% attending 4+ antenatal visits. Exclusive breastfeeding for 6 months increased from 3.2% to 32% (KDHS). The number of infants tested by PCR increased from 4,500 in 2006 to 64,000 in 2011. PCR positivity has dropped from 11.2% (2010) to 7.6% (2011) and 5.2% (2012) at 6-week testing of infants. <h3>Conclusion</h3> Use of more efficacious regimen including Option B+, integration of services, implementation of new guidelines and eMTCT framework should enable Kenya to attain a transmission rate less than 5% by 2015.

Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs?

IntroductionThe current mainstream practice in otolaryngology departments relating to the use of prophylactic antibiotics in epistaxis patients requiring nasal packing is highly variable. This is due primarily to the lack of any validated guidelines. As such, we introduced a new treatment algorithm resulting in significant reduction of use in the systemic antibiotics, with emphasis instead on the use of topical antibiotics. The results were validated through a complete audit cycle.MethodsA total of 57 patients undergoing nasal packing for spontaneous epistaxis were studied. Reaudit occurred after the implementation of new guidelines. Telephone surveys were conducted six weeks after hospital discharge, assessing infective nasal symptoms as well as rebleeding and readmission rates.ResultsSystemic antibiotic prescribing in anterior nasal packing fell by 58.2% between audit cycles with no statistically significant associated increase in infective nasal symptoms, rebleeding or readmission rates six weeks following hospital discharge.ConclusionsSystemic prophylactic antibiotics are unnecessary in the majority of epistaxis patients with nasal packs. The use of topical antibiotics such as Naseptin® may be more appropriate, cheaper and as effective. Implementation of this treatment algorithm will help standardise systemic antibiotic usage in epistaxis patients with nasal packing and should reduce costs associated with unnecessary use of such medication.

Direct mail improves knowledge of basic life support guidelines in general practice: a randomised study

BackgroundImplementation of new guidelines into clinical practice is often incomplete. Direct mail is a simple way of providing information to physicians and may improve implementation of new guidelines on basic life support (BLS). The aim of this study was to describe knowledge of the most recent European Resuscitation Council (ERC) Guidelines for BLS among general practitioners (GPs) and investigate whether direct mail improves theoretical knowledge of these guidelines.MethodsAll general practice clinics (n=351) in Central Denmark Region were randomised to receive either direct mail (intervention) or no direct mail (control). The direct mail consisted of the official ERC BLS/AED poster and a cover letter outlining changes in compression depth and frequency in the new guidelines. In general practice clinics randomised to intervention, every GP received a direct mail addressed personally to him/her. Two weeks later, a multiple-choice questionnaire on demographics and BLS guidelines were mailed to GPs in both groups.ResultsIn total, 830 GPs were included in this study (direct mail, n=408; control, n=422). The response rate was 58%. The majority (91%) of GPs receiving direct mail were familiar with BLS Guidelines 2010 compared to 72% in the control group (P<0.001). Direct mail improved knowledge of the new recommended chest compression depth (67% vs. 40%, P<0.001) and chest compression frequency (62% vs. 40%, P<0.001).ConclusionDirect mail improved knowledge of changes in BLS guidelines and thus facilitated the implementation of this knowledge into clinical practice. Resuscitation councils and medical societies may consider using direct mail as a simple strategy to facilitate implementation of changes in clinical guidelines.