Improve Guideline Adherence Research Articles

“My T Cell”: A Smartphone Application for Guidance of CAR T Logistics and Management of CAR T & BiTE Related Toxicities

The Bispecific T-cell engager (BiTE) Blinatumomab and CD19-specific Chimeric Antigen Receptor (CAR) T-cell products are approved for the treatment of relapsed and refractory B-cell neoplasms. However, these T-cell based immunotherapies can be accompanied by immune-related toxicities differing from adverse events of classical cytotoxic agents. Toxicity management can pose a challenge for health care professionals. Additionally, logistics of CAR T-cell patient management, particularly with regard to timelines of apheresis, bridging therapies, and CAR T-cell transfusion, require coordinated efforts between referring physicians and treatment centers. To support the optimal management of these patients, we developed an interactive smartphone application (“myTcell”) which educates physicians in the pre-treatment logistics of CARs and BiTEs and provides recommendations on management and treatment of immune-related toxicities.We initiated a multi-step content development process with an extensive literature research of toxicity guidelines consented by the ASTCT, SITC, NCCN and EBMT as well as of officially released drug information. Findings were integrated in an information platform to provide diagnostic and therapeutic recommendations as well as algorithms for interactive toxicity grading tools. We could successfully implement an app (“myTcell”) guiding health workers in a disease- and product-specific step by step process through the clinical workflow of CAR and BiTE therapy (Fig.1). This includes recommendations for eligibility, patient screening, safety assessment and stopping rules prior to leukapheresis and CAR T-cell transfusion. Upon entering relevant clinical data for grading of CRS, ICANS and HLH, interactive tools display toxicity grade and grade-specific management (Fig. 2). Further, “myTcell” assists with the diagnosis and treatment of pancytopenia and infections. The app includes an overview of important publications with direct links to respective abstracts to support evidence-based decision-making. A prototype was validated at five Geman treatment centers through a questionnaire which measured the advantage of the app compared to common clinical practice.38 physicians with a median working experience of 8 years validated the app protoype in a real-world setting of CAR T-cells or BiTE application for the treatment of Diffuse Large-B-Cell Lymphoma (89.5%) and B-Cell Precursor Acute Lymphoblastic Leukemia (39.5%) at five German treatment centers (University Hospitals of LMU Munich, Cologne, Göttingen, Erlangen, Tübingen). 78.9% of the users most valued the content of toxicity management. In addition, 63.2% reported to dominantly use the interactive tools and calculators to assess severity of toxicities and to instantly receive grade-specific management recommendations. As expected, the tools were most frequently used for the two most commonly occurring side effects CRS (68.4%) and ICANS (65.8%). In addition, most of the users agreed, that the interactive tools improved toxicity management (94.7%) and saved time during their clinical practice (81.6%). Based on these results, “myTcell” has been certified as a medicinal product class I and has been released in the app stores and for desktop application (www.mytcell.de) on July 15, 2021.“myTcell” is a smartphone app supporting the use of T-cell based immunotherapy platforms. The app supports assessment and treatment of novel CAR T and BITE mediated immunotoxicities. Health care professionals validated feasibility and in particular appreciated fast and easy assessment of toxicity grading and management. Thus, “myTcell” is a tool that has the potential to improve guideline adherence and accelerate broader and safer application of CARs and BiTEs based immunotherapy. [Display omitted] DisclosuresBlumenberg: Novartis: Consultancy, Research Funding; BMS/Celgene: Research Funding; Janssen: Research Funding; Kite/Gilead: Consultancy, Research Funding. Schmidt: Bayer Healthcare: Research Funding; Novartis: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses; Kite/Gilead: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses, Research Funding; Janssen: Other: Travel, Accommodations, Expenses; Takeda: Consultancy, Other: Travel, Accommodations, Expenses; BMS: Consultancy, Other: Travel, Accommodations, Expenses. von Bergwelt: Astellas: Honoraria, Research Funding, Speakers Bureau; Mologen: Honoraria, Research Funding, Speakers Bureau; Miltenyi: Honoraria, Research Funding, Speakers Bureau; MSD Sharpe & Dohme: Honoraria, Research Funding, Speakers Bureau; Kite/Gilead: Honoraria, Research Funding, Speakers Bureau; BMS: Honoraria, Research Funding, Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Roche: Honoraria, Research Funding, Speakers Bureau. Buecklein: BMS/Celgene: Consultancy, Research Funding; Miltenyi: Research Funding; Kite/Gilead: Consultancy, Honoraria, Other: Congress and travel support, Research Funding; Amgen: Consultancy, Honoraria; Novartis: Consultancy, Other: congress and travel support, Research Funding, Speakers Bureau; Pfizer: Consultancy, Honoraria, Speakers Bureau. Subklewe: Janssen: Consultancy; Gilead: Consultancy, Research Funding, Speakers Bureau; Roche: Research Funding; Takeda: Speakers Bureau; Klinikum der Universität München: Current Employment; BMS/Celgene: Consultancy, Research Funding, Speakers Bureau; Amgen: Consultancy, Research Funding, Speakers Bureau; Miltenyi: Research Funding; Seattle Genetics: Consultancy, Research Funding; Pfizer: Consultancy, Speakers Bureau; Novartis: Consultancy, Research Funding, Speakers Bureau; MorphoSys: Research Funding.

Barriers to Clinical Practice Guideline Implementation Among Physicians: A Physician Survey.

IntroductionClinical practice guidelines can help physicians provide evidence-based, standardized clinical decisions. We aimed to assess physician attitudes toward and barriers to guideline adherence.MethodsWe conducted a single center, cross-sectional, survey-based study. Physicians from many specialties participated in the study. All outcomes were measured using a validated survey tool. The primary outcome of interest was barriers to guideline adherence. Secondary outcomes included general attitudes toward guidelines and factors that could improve adherence to guidelines. Outcomes were measured by the survey tool. All outcomes were reported on a 5-point Likert scale.ResultsThe email survey was received by 1819 physicians with 400 responders (22% response rate). About 50% (n=200) were in practice for >5 years, while 27% (n=107) were still in training. Trainees were less likely to understand the process of guideline development (RR= 0.76 [0.65–0.88], p=0.0017), to have input in guideline development (RR= 0.52 [0.41–0.65], p<0.0001), and to report up-to-date knowledge in practice guidelines (RR=0.53 [0.30–0.73], p=0.0002). Three factors were identified as major barriers to guideline adherence: complexity of guideline documents (61%, n=240), high number of weak or conditional recommendations (62%, n=245), and time constraints due to clinical responsibilities (65%, n=255). Factors that would improve guideline adherence included access to relevant guidelines at the point of care (87%), improved focus on guidelines during training (82%), and transparency on physician commercial affiliation (62%).ConclusionImproved focus on guidelines during training and access to relevant guidelines at the point of care may be important to improve adherence to guidelines.

1473 Urology Consent Forms at a District General Hospital – a Quality Improvement Project

Abstract Aim Consent is a core component of interaction between patients and healthcare professionals. Prior to surgery, forms are completed to record patient consent. As well as containing risks and benefits of the procedure, the consent form, as per guidelines1,2, must be legible and suitable to a patient’s capacity. To evaluate compliance with local and national guidelines, a quality improvement project was undertaken at a district general hospital. Method Over a three-week period 30 urology consent forms were selected to assess adherence to local and national guidelines. The appropriateness of consent form, patient signature, legibility, acronym use and whether the patient was offered a carbon copy were assessed. After initial data collection, all urology staff consenting patients were notified of the findings and how best to improve guideline adherence. A further three-week data collection was undertaken, though the sample set was small due to Coronavirus and Christmas. Results The results confirmed that patients had appropriate consent forms filled out and were signed appropriately. After intervention, there was clear improvement in legibility, with no low legibility consent forms, and 100% vs 83% high or moderate legibility between data sets. Intervention also resulted in significant reduction of acronym use; 33% vs 60%. More patients were also offered to retain a carbon copy; 89% vs 40%. Conclusions Through this intervention of highlighting local and national guidance as compared to current practice, compliance drastically improved. As the pandemic subsides, we hope regular emails to surgical teams will improve consent form completion to better patient care.

Multifaceted intervention including Facebook-groups to improve guideline-adherence in ICU: A quasi-experimental interrupted time series study.

The impact of social media, with its speed, reach and accessibility, in interventions aimed to improve adherence to guidelines such as assessment of Pain, Agitation/Sedation and Delirium (PAD) in intensive care is not described. Therefore, the primary objective of this quality improvement study was to evaluate the impact of a multifaceted intervention including audit and feedback of quality indicators (QI) via Facebook-groups, educational events and engagement of opinion leaders on adherence to PAD-guidelines in four ICUs. A quasi-experimental interrupted time series study with eight monthly data points in the two phases Before and Intervention was designed. Proportion of nursing shifts with documented PAD-assessment (PAD-QIs) were retrieved from the electronical medical chart from included adult ICU patient-stays in four participating ICUs. Difference between the two time periods was assessed using generalised mixed model for repeated measures with unstructured covariance matrix, and presented as Beta (B) with 95% confidence interval (CI). Finally, 1049 ICU patient-stays were analysed; 534 in Before and 515 in Intervention. All three PAD-QIs significantly increased in Intervention by 31% (B=30.7, 95%CI [25.7 to 35.8]), 26% (B=25.8, 95%CI [19.4 to 32.2]) and 34% (B=33.9, 95%CI [28.4 to 39.4]) in pain, agitation/sedation and delirium, respectively. A multifaceted intervention including use of Facebook-groups was associated with improved guideline-adherence in four ICUs, as measured with process PAD-QIs of PAD assessment. Further research on use of social media to improve guideline adherence is warranted, particularly as social distancing impacts clinical education and training and new approaches are needed.

A cluster randomized trial to evaluate a centralized remote clinical pharmacy service in large, health system primary care clinics.

We developed a remote cardiovascular risk service (CVRS) managed by clinical pharmacists to support primary care teams. The purpose of this study was to examine whether the CVRS could improve guideline adherence in primary care clinics with diverse geographic and patient characteristics. This study was a cluster-randomized trial initiated in 20 primary care clinics across the US. Clinics were stratified as high or low minority and then randomized to receive the intervention or maintain usual care for 12 months. The primary outcome was adherence to relevant The Guideline Advantage (TGA) criteria met. TGA is a compilation of criteria from practice guidelines intended to improve the quality of primary care. Post-hoc outcomes included changes in individual TGA measures. A total of 401 study subjects were included in the analysis. Mean TGA scores remained the same in the intervention group (n=193, 0.72) and slightly decreased in the usual care group (n=208, 0.67 to 0.66) over the 12-month study period. There was no significant difference between the mean TGA scores in intervention and usual care groups for the overall population at 12 months (0.72 versus 0.66 respectively, p=0.10). For under-represented minority subjects, there was no significant difference between TGA scores at 12 months (n=186; 0.70 versus 0.67, respectively, p=0.50). In a post-hoc analysis of subjects uncontrolled at baseline, there was a significant improvement in systolic BP at 12 months in the intervention group versus usual care (model-based difference of -8.03mmHg, p=0.03). Improvements in individual TGA measures were limited, in part, due to higher than expected baseline TGA scores. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. ClinicalTrials.gov Identifier: NCT02215408; https://clinicaltrials.gov/ct2/show/NCT02215408?id=NCT02215408.

Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels. The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions. The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

Radiology report language positively influences adrenal incidentaloma guideline adherence

BackgroundAdrenal incidentalomas are common radiographic findings. Guidelines recommend biochemical and radiographic surveillance of adrenal incidentalomas. We investigated if patients were appropriately referred for outpatient evaluation. MethodsRetrospective chart review was performed to identify patients with adrenal masses on imaging between November 7, 2016 and November 7, 2017. Demographic information, medical history, and outpatient referral information was collected. Results11,723 computed tomography (CT) scans of the chest and/or abdomen/pelvis were performed. 246 patients were noted to have adrenal incidentalomas and met inclusion criteria. The CT report recommended follow-up in 63/246 cases (25.6%). 38/246 (15.4%) patients were referred for evaluation. Age, adrenal nodule size, and type of evaluating provider did not affect referral. A radiology report recommending follow-up was associated with increased referral rate (OR 5.441, 95% CI: 2.491–11.887). ConclusionThere was low outpatient referral for adrenal incidentalomas. Language in the radiology report significantly influenced referral rates and may be an important resource for improving guideline adherence.

Impact of a Multidisciplinary Long-Term Opioid Therapy Safety Program at a Military Tertiary Academic Medical Center.

In light of the ongoing opioid crisis, Naval Medical Center Portsmouth (NMCP) created the Long-Term Opioid Therapy Safety (LOTS) program to reduce risks and improve long-term opioid therapy outcomes. Our primary outcome was change in compliance with the recommended safety metrics. This is a retrospective cohort study performed at NMCP, a large military academic medical center providing comprehensive medical care to DoD beneficiaries. The NMCP LOTS program provides both patient and provider narcotic education as well as medical record auditing. The NMCP LOTS program promotes adherence to published CDC, the DVA, and DoD guidelines. Anonymized data were compiled each fiscal quarter and were analyzed retrospectively. Adult patients prescribed opioids for at least 90 days without a gap of 30 days between prescriptions were included in this study. The investigators recorded and reported provider compliance with LOTS metrics over the same period. Compliance with the recommended safety metrics improved. We noted a decrease in the number of long-term opioid patients, concurrent benzodiazepine prescriptions, and patients prescribed greater than 90 morphine equivalents per day during the observation period. The number of naloxone prescriptions for LOTS patients also increased, reflecting improved guideline adherence. Systematic education and feedback to providers are effective in creating a system and culture of opioid reduction, safe opioid prescribing, and system accountability. This article presents a comprehensive approach to modifying prescribing patterns of long-term opioids in a large healthcare system.

Collaborative Physician-Pharmacist Multiple Myeloma Clinic Improves Guideline Adherence and Prevents Treatment Delays

Although survival of patients with multiple myeloma (MM) has improved in the last decade, achieving optimal outcomes requires timely delivery of anti-myeloma therapy as well as adherence to supportive care guidelines and patient education. We hypothesized that a multidisciplinary approach of a collaborative physician-pharmacist MM clinic would have a positive impact on clinical measures such as guideline adherence as well as improve the workflow process and prevent treatment delays.From March 2014 to February 2015, we initiated a collaborative MM clinic at our institution, whereby in addition to normal physician care, a dedicated board-certified oncology pharmacist provided consultation on all new and continuing patients. The pharmacist provided education and medication lists, completed medication reconciliation, monitored for adherence and side effects, recommended management of toxicity and supportive care, and navigated issues involving enrollment and access to oral specialty medications. All consultations were documented in the patient's medical chart using a template addressing these key components. Outcomes were compared to those of patients being treated by the same physician during the previous year, when ad-hoc pharmacist consultation was available (traditional model). We compared clinical measures related to guideline adherence and analyzed delays in obtaining immunomodulator drugs (IMiDs) using available dispensing records.Patient characteristics were similar between the collaborative and traditional models including age, sex, race, ISS stage, protein subtype, treatment type, and prior number of therapies. During the 12-month study period when a collaborative model was implemented, 399 pharmacist consultations occurred during 551 physician visits (n=57 patients). During the prior year when a traditional model existed, there were 26 pharmacist consultations on 355 physician encounters (n=44 patients) (7.3% versus 72.4%, p<0.0001).We observed improved adherence to bisphosphonates (BP) in the collaborative clinic (55 (96%) versus 30 (68%) patients, p=0.0002). Among patients receiving BP, the time to initiation from diagnosis and re-initiation after autologous stem cell transplant (ASCT) was 5.5 versus 97.5 days (p<0.001) and 12.5 versus 135 days (p<0.001) among the collaborative and traditional clinic, respectively. One hundred percent of patients in the collaborative clinic versus 41% of patients in the traditional clinic received concomitant calcium and vitamin D (p<0.001). In patients receiving IMID-based regimens, appropriate VTE prophylaxis was prescribed in 52 (100%) versus 29 (76%) patients in the collaborative and traditional clinic, respectively (p<0.0002). Appropriate use of acyclovir prophylaxis in patients receiving proteasome inhibitor-based treatment was observed more frequently in the collaborative clinic (98% versus 56%, p=0.004). Although the number of patients receiving Pneumocystis Jirovecii pneumonia prophylaxis post-ASCT was similar (93 versus 100 percent, p=0.4), the time to initiation of prophylaxis was shorter in the collaborative clinic (11 versus 40.5 days, p<0.0001). Finally, influenza vaccination administration was higher in the collaborative clinic (76 versus 24 percent, p<0.001). When analyzing delays in obtaining IMiD therapy, we found that the median time from when the treatment plan was noted in the medical chart to when the IMiD was first filled was 7 (range: 0-32) vs. 15 (range: 3-62) days in the collaborative and traditional clinic, respectively (p=0.002). Finally, there was a significant reduction in treatment delays observed in the collaborative compared to the traditional clinic (21% vs. 85% of patients undergoing a delay, p<0.0001).Here we pilot a multidisciplinary approach that leads to increased guideline adherence and prevents delay in anti-myeloma treatment. The collaborative clinic model could be applied to several different practice sites in order to establish an improved and more systematic approach in the management of MM patients. Prospective studies analyzing clinical outcomes, patient satisfaction and cost effectiveness of this approach are warranted. DisclosuresWirth:Celgene: Consultancy, Honoraria. Patel:Celgene: Consultancy, Honoraria.

Infection control, prophylactic antibiotics, and testing for SARS-CoV-2 and PPE on German intensive care units: results from a national mixed methods survey.

Aim: Recommendations on hygiene measures, personal protective equipment (PPE), isolation, and antibiotic prophylaxis were developed during the coronavirus 2019 disease (COVID-19) pandemic and have been revised several times to date. Some of the underlying literature indicates a large evidence gap. We suspect that this leads to a large variance of measures on German intensive care units (ICU).Methods: A mixed methods online survey among intensive-care specialists in Germany caring for COVID-19 patients was conducted in December 2020.Results: We received responses from 205 German ICUs that had treated COVID-19 patients to date. There was wide variation in the use of PPE. Polymerase Chain reaction (PCR) testing for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) was used by 94.8% of the units, with an average waiting time of 12 hours for the result. 18.7% of the respondents prescribed antibiotic prophylaxis in COVID-19 patients.Conclusion: We found a high variance in essential care strategies for COVID-19 patients on German intensive care units. This included differences in infection prophylaxis, personal protective equipment, and the indication of prophylactic antibiotic therapy. Based on our results, we recommend further studies to quantify and improve guideline adherence.

OR4. Emphasis on Post-Acute Care Shows Improved Guideline Adherence in Three Metro Markets

<h3>Background</h3> Nearly 6.5 million Americans are living with heart failure. Heart failure remains a leading cause of hospital admission and contribution to healthcare expenditure. It is projected that by the year 2030, the total cost of heart failure will increase by 127%. Participation in a quality improvement initiative aimed at improving adherence to evidenced based guidelines can assist in reducing cost and improving patient outcomes. While hospital participation in an in-hospital quality improvement initiative, such as Get With the Guidelines® Heart Failure (GWTG-HF), has been well-studied, few studies evaluate post-hospital discharge adherence to guideline directed medical therapy. <h3>Objective/Purpose</h3> The objective of this initiative was to create a streamlined easy-to- use post hospital discharge data collection tool, provide quality consultation to utilize data, and form learning collaboratives to share best practice for improving quality of care. <h3>Methods</h3> A multidisciplinary learning collaborative consisting of 40+ hospitals and post-acute care organizations (home health, community paramedicine, skilled nursing facilities, assisted living) was established in three metro markets: St. Louis, Milwaukee, and Chicago. Utilizing feedback from these collaborative groups, a post-acute care data collection form aimed in tracking adherence to guideline- based care was created in GWTG-HF. Hospitals abstracted data into this form beginning with Quarter 3 2019. Data collected was used to guide collaborative group discussion and individual hospital quality consultation aimed at improving patient outcomes across the care continuum. Additional educational guideline-based resources were provided including webinars, conferences, pocket cards, podcasts, order set examples and follow-up phone call templates. <h3>Results</h3> Hospitals entered baseline data from Quarter 3 2019. Data was reviewed from Quarter 3, 2020 for follow-up comparison. Compliance with post-acute measures improved from baseline Q3, 2019 to Q3, 2020 as follows: ACEI/ARB/ARNI 76.9% to 82.4% (+5.5%), Aldosterone Antagonist 58.2% to 64.9% (+6.7%), and Participation in either Cardiac Rehab or Disease Management 58.7% to 66.1% (+7.4%). <h3>Conclusions</h3> Before this initiative, few of the hospitals in the learning collaborative were focusing on post-acute follow up care or collecting data to review. Once a streamlined, easy-to-use post-acute care data collection form was created, all the hospitals in the collaborative were required to use it. Reviewing data, providing education, establishing collaborative teams across the care continuum, and sharing best practices moderately improved post-acute care. Future studies should consider including post-acute care organizations performing data collection to improve data accuracy and provide a comprehensive portrayal of patient follow-up care. Future studies should also consider evaluating post-acute care beyond 30 days of hospital discharge.

Compliance With an Antibiotic Guideline for Suspected Ventilator-Associated Infection: The Ventilator-Associated INfection (VAIN2) Study.

To evaluate a guideline for antibiotic decisions in children with suspected ventilator-associated infection. Prospective, observational cohort study conducted in 22 PICUs in the United States and Canada. PICUs in 22 hospitals from April 2017 to January 2019. Children less than 3 years old on mechanical ventilation greater than 48 hours who had respiratory secretions cultured and antibiotics initiated for suspected ventilator-associated infection. After baseline data collection in children with suspected ventilator-associated infection (Phase 1), a consensus guideline was developed for advising antibiotic continuation or stopping at 48-72 hours (Phase 2) and implemented (Phase 3). Guideline-based antibiotic recommendations were provided to the treating clinicians once clinical and microbiologic data were available. Demographic and outcome data were collected, and guideline compliance and antibiotic utilization evaluated for Phase 1 and Phase 3. Despite education and implementation efforts, guideline-concordant antibiotic management occurred in 158 of 227 (70%) Phase 3 subjects compared with 213 of 281 (76%) in Phase 1. Illness severity and positive respiratory cultures were the primary determinants of antibiotic continuation. For subjects with a positive respiratory culture but a score for which antibiotic discontinuation was recommended (score ≤ 2), only 27% of Phase 3 subjects had antibiotics discontinued. Antibiotic continuation was not associated with improved outcomes in these subjects and was associated with significantly longer duration of ventilation (median 5.5 d longer) and PICU stay (5 d longer) in the overall study population. Positive respiratory cultures were not associated with outcomes irrespective of antibiotic treatment. Antibiotic guideline efficacy and safety remain uncertain due to clinician failure to follow the guideline, instead primarily relying on respiratory culture results. Strategies to overcome clinician perceptions of respiratory cultures and other barriers will be vital for improving guideline adherence and antibiotic use in suspected ventilator-associated infection in future studies.

A retrospective validation of different scores of guideline adherence and infectious diseases consultation on candidaemia: The higher, the better.

Recently, several scores to quantify compliance with the guidelines in candidaemia management (EQUAL, GEMICOMED, Valerio) have been developed. Evidence supporting the association of these scores to the prognosis is scarce. We aim to evaluate the performance of these candidaemia guideline adherence scores to predict candidaemia outcome. We recorded retrospectively data from candidaemia episodes (January 2017-December 2018). We analysed adherence to guidelines for candidaemia management according to EQUAL, GEMICOMED and Valerio scores, and we correlated those to outcome. Fifty-four first episodes of candidaemia were retrieved. Five patients who died in the first 48hours after blood cultures were not included. Thirty-day mortality in evaluable patients was 18.4%. Median adherence to guidelines according to EQUAL score was 17 (interquartile range [IQR]: 15-19), and according to GEMICOMED was 86% (IQR: 72.5%-100%). According to Valerio score, adequacy of antifungal prescription was 8.5/10 (SD: 1.9). A cut-off of ≥17 for EQUAL or compliance >70% for GEMICOMED was associated with inferior 30-day mortality (7.1% vs 33.3%, P=.028 and 7.9% vs 54.5%, P=.002, respectively). Infectious diseases (ID) evaluated cases obtained a better EQUAL score (>17; 82.1% vs 42.9%, P=.006), had inferior 30-day mortality (9.4% vs 35.3%, P=.049) and a better antifungal prescription adequacy (Valerio score 9.0 vs 7.5, P=.011). Adherence to guidelines for candidaemia management evaluated by means of EQUAL and GEMICOMED score was associated with a decreased 30-day mortality. Adequacy of antifungal prescription can be ameliorated. ID consultation improved guideline adherence and was associated with decreased 30-day mortality.

Practice Patterns for Prevention of Chemotherapy-Induced Nausea and Vomiting and Antiemetic Guideline Adherence Based on Real-World Prescribing Data.

Guideline-recommended antiemetic prophylaxis improves nausea and vomiting control in most patients undergoing chemotherapy. Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology (MASCC/ESMO) antiemetic guidelines recommend prophylaxis with a neurokinin-1 receptor antagonist (NK1 RA), a 5-hydroxytryptamine-3 receptor antagonist (5-HT3 RA), and dexamethasone for patients receiving highly emetogenic chemotherapy (HEC), including anthracycline-cyclophosphamide (AC)- and carboplatin (considered moderately emetogenic chemotherapy)-based chemotherapy. Here, we analyze the use of NK1 RA-5-HT3 RA-dexamethasone for antiemetic prophylaxis associated with HEC and carboplatin. The data source was the Global Oncology Monitor (Ipsos Healthcare). Geographically representative physicians from France, Germany, Italy, Spain, and the U.K. were screened for treatment involvement and number of patients treated per month. Patients' data from January to December 2018 were collected from medical charts and extrapolated on the basis of the total number of physicians who prescribe chemotherapy. The emetic risk of chemotherapy was classified per MASCC/ESMO guidelines. Data from 45,324 chemotherapy-treated patients were collected, representing a total extrapolated prevalence of 1,394,848 chemotherapy treatments included in the analysis. NK1 RAs were used in 45%, 42%, and 19% of patients receiving cisplatin-, AC-, and carboplatin-based chemotherapy, respectively; 18%, 24%, and 7% received the guideline-recommended NK1 RA-5-HT3 RA-dexamethasone combination; no antiemetics were prescribed for 12% of the treatments. Often, physicians' perception of the emetic risk of chemotherapy did not follow MASCC/ESMO guideline classification. Low adherence to antiemetic guidelines was revealed in clinical practice in five European countries, with 15% of all HEC-/carboplatin-based treatments receiving guideline-recommended NK1 RA-5-HT3 RA-dexamethasone prophylaxis and 12% of them receiving no antiemetics. New strategies for improving guideline adherence are urgently needed. Despite recent advances in antiemetic therapy, a substantial proportion of patients experience nausea and vomiting associated with chemotherapy in daily clinical practice. Antiemetic guidelines aim at prevention of chemotherapy-induced nausea and vomiting (CINV), and guideline-consistent antiemetic therapy can effectively prevent vomiting and, to a lesser extent, nausea in most patients with cancer. This study reports low adherence to antiemetic guidelines in the highly emetogenic chemotherapy setting in daily clinical practice across five European countries. Opportunity exists to increase adherence to antiemetic guideline recommendations. Implementation of strategies to facilitate guideline adherence can potentially improve CINV control.

Widespread gaps in the quality of care for primary biliary cholangitis in UK

ObjectivePrimary biliary cholangitis (PBC) is a progressive, autoimmune, cholestatic liver disease affecting approximately 15 000 individuals in the UK. Updated guidelines for the management of PBC were published by The...

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU.

Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice. A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed. 314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p<0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p<0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p=0.001). 2/3 of respondents (n=173, 66%) stated more research on ICU vascular access was needed. Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

Routine follow-up of native valve disease: real life data from a physiologist-led valve clinic

Abstract Funding Acknowledgements Type of funding sources: None. Purpose The 2014 American Heart Association (AHA) guidelines for the management of Valvular Heart Disease (VHD) suggest that patients with mild and moderate native VHD should be followed up with echocardiography at regular intervals. Following audits at our hospital in 2016, dedicated Physiologist Led Valve Clinics (PLVC) were initiated to improve guideline adherence. A conservative strategy for follow-up frequency based on AHA guidelines was chosen (3 years for mild VHD, and 1 year for moderate VHD). This audit aimed to ascertain adherence to this conservative follow-up strategy, and to assess the progression of VHD between echocardiographic assessments to inform a strategy for safe follow-up in our PLVC. Methods Our echocardiography database Cognos was searched for patients with isolated mild and moderate native VHD, seen in our PLVC between 2016-2018 and followed up between 2017-2019. Patients with severe, prosthetic, combined or significant mixed VHD were excluded. Echocardiography reports on McKesson were reviewed and the follow-up interval recorded for each patient. The severity of VHD at the index visit, and then at follow-up, was recorded to determine whether there had been a progression in VHD severity. For patients with progression, it was recorded whether they were symptomatic at follow-up or subsequently underwent valvular intervention. Results 466 index echocardiograms were reviewed; 134 patients were included (mean age 73.4) after removing those with exclusion criteria. The mean follow-up interval in mild VHD ranged between 587.6 ± 188.3 days, and 667.3 ± 174.6 days, well above the recommended 3 years (or 1095 days). The majority of patients with moderate VHD received follow-up well before the upper limit of AHA guidance (2 years, or 730 days). Mean follow-up ranged between 408.3 ± 80.8 days (in moderate aortic stenosis (AS)) and 504.0 ± 29.0 days (in moderate mitral stenosis (MS)). The number of patients followed up with mild VHD was very low. 1 patient in each group progressed to moderate VHD (out of 2, 3 and 5 respectively); none became symptomatic, and none progressed from mild to severe VHD. In moderate VHD, progression rates were highest in AS (34.8%). Patients with progressive disease were more frequently symptomatic (43%) or underwent valve intervention (25%). Fewer with mitral regurgitation (MR) (22%) progressed, 44.5% of whom were symptomatic, 11% undergoing intervention. Patients with moderate aortic regurgitation (AR) saw the lowest progression rates (11.4%), 50% of whom were symptomatic. There was no progression in moderate MS. Conclusions Patients with mild VHD can safely be followed up less conservatively in the PLVC setting, adhering to AHA guidance (3-5 years). Patients with moderate AS should be considered to remain under conservative follow-up (12-18 months). Follow-up for moderate AR, MR and MS can safely be adjusted towards the less conservative end of the AHA guidance (2 years). Abstract Figure.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

BackgroundCommunity hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate...

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discuss strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization.

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discusses strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.