Publication Of National Guidelines Research Articles

430 Evidence-based stillbirth evaluation deficiencies remain following publication of national guidelines

430 Evidence-based stillbirth evaluation deficiencies remain following publication of national guidelines

Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices

Background: The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life. Methods: We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices. Results: We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in >75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (>75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200–300 mL/min and 400–600 mL/min, respectively. The dose of dialysis for continuous RRT was 25–35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine). Conclusion: This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

Bronchiolitis is a common lower respiratory tract infection that affects infants and young children. Because of variability in physician practice, inpatient management varies among pediatricians. In 2014, the Canadian Pediatric Society published national guidelines aimed at standardizing the inpatient management of this illness, which included recommending against the need for antibiotics for most patients. The study objective was to evaluate antibiotic prescription and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. This study was a single-center retrospective chart review of inpatients with bronchiolitis. We included healthy children 1 to 24 months of age who were admitted from November 2011 to October 2016. Those admitted before December 2014 were analyzed in the preguidelines cohort; the remaining, in the postguidelines cohort. The main outcome was antibiotic prescription. The secondary outcome was the frequency of chest radiographs, nasopharyngeal swabs, and blood cultures. A total of 131 patients were included in the first cohort; 71, in the second cohort. The rates of antibiotic initiation were almost equal in both cohorts (∼44%; P = .98). More antibiotics were discontinued during hospitalization in the second cohort compared with the first cohort (10% vs 20%; P = .001). Significantly fewer patients were discharged with antibiotics in the second cohort (31% vs 16%; P = .02). Our study revealed a reduction in antibiotic use after the release of national guidelines, illustrating that antibiotic prescribing practices can change. However, there is still a pressing need for local initiatives to continue to reduce the unnecessary use of antibiotics within the pediatric setting.

Ambulatory Antibiotic Prescribing for Children with Pneumonia After Publication of National Guidelines: A Cross-Sectional Retrospective Study.

IntroductionNational guidelines published in 2011 recommend amoxicillin as first-line treatment for non-hospitalized children with community-acquired pneumonia (CAP). We aimed to understand visit rates, antibiotic selection, and factors associated with amoxicillin prescribing for children with CAP since guideline publication.MethodsWe performed a cross-sectional retrospective study of patients aged 90 days–18 years with an outpatient clinic or emergency department (ED) visit from 2008 to 2015 using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey ED data files, respectively. We estimated the incidence rates of ambulatory CAP visits, examined time trends in antibiotics prescribed at CAP visits, and determined factors independently associated with first-line guideline-recommended antibiotic prescribing using multivariable logistic regression, including patient age, setting, and US census region.ResultsFrom 2008 to 2015, there were an estimated 1.5 million [95% confidence interval (CI) 1.3–1.7 million] pediatric CAP visits annually. Amoxicillin was prescribed in 23% (95% CI 18–30%), azithromycin was prescribed in 47% (95% CI 41–54%), and cephalosporins were prescribed in 26% (95% CI 21–31%) of antibiotic visits for CAP. There were no significant differences in annual CAP visits or prescribing by antibiotic class since guideline publication. Amoxicillin prescribing was significantly less likely in visits by older children, aged 5–18 years, [adjusted odds ratio (aOR) 0.22, 95% CI 0.10–0.49] compared to visits by younger children aged 90 days–4 years with CAP. Compared with the Northeast, amoxicillin prescribing was significantly lower in the Midwest (aOR 0.35, 95% CI 0.13–0.98) and South (aOR 0.23, 95% CI 0.08–0.63). Azithromycin prescribing was significantly more likely in visits to EDs (aOR 1.46, 95% CI 1.07–1.98) compared to physician offices.ConclusionDespite national guideline recommendations, amoxicillin prescribing for CAP in outpatient settings is low and azithromycin remains the predominant antibiotic prescribed, highlighting the need for dedicated antibiotic stewardship efforts in ambulatory settings.

Variations in Insurance Policies Regarding Adherence to the AGA Guideline for Therapeutic Drug Monitoring in IBD.

The American Gastroenterological Association (AGA) published guidelines on therapeutic drug monitoring (TDM) in inflammatory bowel disease (IBD) in August 2017 recommending use of reactive TDM to guide treatment changes in patients with active IBD who are being treated with anti-tumor necrosis factor (anti-TNF) agents or thiopurines. We sought to determine if changes in national clinical practice guidelines result in changes in health care insurance policies within 6 months of publication. Using the National Association of Insurance Commissioners Market Share Reports of the top 125 insurance companies by market share in 2016, we reviewed the largest 50 companies for their publicly available online policies regarding TDM of anti-TNF and thiopurine in IBD. For those with available policies, we looked for whether proactive and/or reactive TDM was covered. Policies were also looked for genetic or enzymatic activity of thiopurine methyltransferase (TPMT) testing before use of thiopurine. All these policies were reviewed within the week of publication of the AGA guideline. They were reviewed again 1, 3, and 6 months later for evaluation of any policy changes after the published AGA guidelines. Fifty of the largest insurance company policies were included. With regards to TDM policy for anti-TNF, we did not find a difference between baseline and 6 months values (P=0.38). With regards to TDM policy for thiopurine, we did not find a difference between baseline and 6 months values (P=1.00). About half of the companies did not have a policy regarding TPMT testing for thiopurine use. Of those with available policies for TPMT testing, there was no difference between baseline and 6 months values (P=0.13). Even after publication of national guidelines, a large number of the largest health insurance companies do not have a policy regarding reactive TDM for anti-TNF and/or thiopurines. Majority of those with a policy, fail to meet the current standards set forth by the practice guidelines. A significant gap remains between the insurance policies and AGA guidelines. Further studies are needed to determine how to effectuate change to improve insurance company adherence to clinical practice guidelines.

Work-up and treatment of prostate cancer before and after publication of the first national guidelines on prostate cancer care in Sweden

Background and Objectives: In 2007, the Swedish National Board of Health and Welfare published the first Swedish guidelines on prostate cancer (PCa) to improve care and decrease geographical and social inequalities. The aim of this analysis was to assess how these guidelines affected PCa care.Materials and Methods: Work-up and treatment for men diagnosed with PCa between 1998 and 2014 were assessed by use of data in the Prostate Cancer data Base Sweden (PCBaSe) with information from the National Prostate Cancer Register (NPCR) and other healthcare registries and demographic databases.Results: Overall, there were modest improvements in the performance for 14 selected quality indicators, with some notable exceptions. There was a strong increase in the use of active surveillance for very low-risk PCa, up from 56% in 2009 to 92% in 2014, and use of bone imaging for high-risk PCa up from 50% in 2008 to 77% in 2014. There were large differences in work-up and treatment of PCa between healthcare providers with modest decreases over time. The differences between counties were larger than differences according to socioeconomic status with one exception: use of curative treatment for high-risk PCa was more common in men with high income, highest versus lowest tertile, OR 2.74 (95% CI, 1.85-4.06).Conclusion: The modest improvements in PCa care after the publications of national guidelines indicate that if these are to make an impact on care, feedback to each point of care on their performance as well as local quality improvement programs implementing the guidelines are needed.

ANTIBIOTIC USE FOR INPATIENT BRONCHIOLITIS: DID NATIONAL GUIDELINES CHANGE PRACTICE?

Abstract BACKGROUND Millions of infants and young children are affected by bronchiolitis annually around the globe. This viral lower respiratory tract infection often results in hospital admissions, thus impacting the cost of the healthcare system. Because of its heterogeneous clinical presentation, inpatient management practices amongst paediatricians varies widely. The publication of national guidelines by the Canadian Paediatric Society (CPS) in 2014 was aimed at decreasing the use of unnecessary investigations and therapies for inpatient management of bronchiolitis. OBJECTIVES To evaluate the levels of antibiotic prescriptions and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. DESIGN/METHODS This study is a single-centre retrospective chart review of inpatients with confirmed cases of bronchiolitis. We included children with no other relevant co-morbidities, aged 1- 24 months, who were admitted from November 2011 – October 2016. We excluded those who were born less than 35 weeks gestational age and patients with chronic complex medical problems. Our inclusion and exclusion criteria mirrored those used in the CPS guidelines. Those admitted prior to December 2014 were analysed in the pre-guidelines cohort and the remaining were placed in the post-guidelines cohort. The main outcome was antibiotic prescription during the hospital stay. Secondary outcomes included the frequency of chest x-rays, nasopharyngeal swabs, and blood cultures. RESULTS 131 patients were included in the first (pre-guideline) cohort and 71 in the second (post- guideline) cohort. The overall initiation of antibiotics was almost equal in both cohorts, regardless of whether a chest x-ray was ordered (p=1.000). There was no significant difference in the number of chest x-rays ordered between cohorts (p=0.099). The percentage of patients discharged on antibiotics were significantly lower in the second cohort (p=0.018). More antibiotics were discontinued after a viral cause was isolated in the second cohort (p=0.001). The gender distribution, mean age and mean length of stay were almost equivalent between the cohorts. CONCLUSION Our study did not show a significant change in antibiotic prescription despite the release of national guidelines. We found that isolating a viral aetiology often leads to the discontinuation of antibiotics. This study emphasizes the need for local antimicrobial stewardship initiatives to reduce the use of unnecessary antibiotics.

Management of varicella-zoster virus primary infection during pregnancy: A national survey of practice

BackgroundVaricella (VZV) infection in pregnancy can result in serious outcomes: maternal pneumoniae irrespective of the term of pregnancy, and lead to congenital varicella syndrome before 18 weeks of gestation and neonatal varicella. There are between 350 and 500 cases a year in France. Until now, there have been no scientific obstetrical guidelines for clinical practice in France for VZV infection during pregnancy. ObjectivesTo evaluate health care providers’ knowledge and practices concerning varicella infection during pregnancy in France. Study designAn anonymous survey on VZV infection was sent by e-mail to gynecologists-obstetricians and midwives. We evaluated their knowledge and practices concerning VZV transmission, maternal varicella, congenital varicella syndrome, neonatal varicella and prevention. ResultsThe survey was completed by 271 professionals: gynecologists (161/271; 60%) and midwives (110/271; 40%). Among 20 items, 5 were multiple choice questions. 29 correct answers were expected. Scores ranged from 6/29 to 28/29 (mean score: 17.44/29). ConclusionsThe consequences of VZV primary infection in pregnancy are poorly known. We reveal a diversity of management among practitioners in our study population, not always in accordance with the international scientific literature or with the guidelines of other countries. Health care providers should update their knowledge of varicella infection during pregnancy. The publication of national guidelines could help to achieve this objective.

Antibiotic Choice for Children Hospitalized With Pneumonia and Adherence to National Guidelines.

The 2011 national guidelines for the management of childhood community-acquired pneumonia (CAP) recommended narrow-spectrum antibiotics (eg, ampicillin) for most children hospitalized with CAP. We assessed the impact of these guidelines on antibiotic prescribing at 3 children's hospitals. Children hospitalized with clinical and radiographic CAP were enrolled from January 1, 2010, through June 30, 2012, at 3 hospitals in Tennessee and Utah as part of the Centers for Disease Control and Prevention Etiology of Pneumonia in the Community study. Antibiotic selection was determined by the treating provider. The impact of the guidelines and hospital-level implementation efforts was determined by assessing the monthly percentage of enrolled children receiving third-generation cephalosporins or penicillin/ampicillin. Segmented linear regression was used to compare observed antibiotic selection in the postguideline period with expected antibiotic use projected from preguideline months. Overall, 2121 children were included. During the preguideline period, 52.8% (interquartile range 47.8-56.6) of children with CAP received third-generation cephalosporins, whereas 2.7% (2.1, 7.0) received penicillin/ampicillin. By 9 months postguidelines, third-generation cephalosporin use declined (absolute difference -12.4% [95% confidence interval -19.8% to -5.1%]), whereas penicillin/ampicillin use increased (absolute difference 11.3% [4.3%-18.3%]). The most substantial changes were noted at those institutions that implemented guideline-related dissemination activities. After publication of national guidelines, third-generation cephalosporin use declined and penicillin/ampicillin use increased among children hospitalized with CAP. Changes were more apparent among those institutions that proactively disseminated the guidelines, suggesting that targeted, hospital-based efforts are important for timely implementation of guideline recommendations.

Impact of New Guidelines and Educational Program on Awareness of Medical Fitness to Drive Among General Practitioners in Ireland

Objective: To investigate changes in attitudes, resources, and practices of general practitioners (GPs) toward evaluating medical fitness to drive (MFTD) following the publication of national guidelines and an extensive educational programme in traffic medicine.Method: Postal questionnaire survey to GPs (n = 1,000) in November 2013.Results: The final response rate was 46%. GPs are confident (57%) or very confident (14%) in assessing MFTD. There is a high awareness of the new Irish guidelines, with 86% of GPs using them for assistance in assessing MFTD. GPs are divided as to whether GPs (49%) or practitioners specially trained to assess MFTD (44%) should be primarily responsible for assessing MFTD. GPs expressed interest in traffic medicine educational programs, most notably a resource pack for continuous medical education (CME) Small Group learning (87%), MFTD software (71%), and an online moodle (68%). Many (68%) remain concerned about their liability in regard to MFTD assessments.Conclusion: Irish GPs are confident in assessing MFTD and show a high level of awareness of the new guidelines. There is a clear interest among GPs in further educational supports and training in traffic medicine, particularly MFTD assessments.

The delivery of heavy menstrual bleeding services in England and Wales after publication of national guidelines: a survey of hospitals

BackgroundIn 2007–2008, two UK-based organisations, the National Institute for Health and Clinical Excellence and the Royal College of Obstetricians and Gynaecologists, published guidelines for the management of care and organisation of outpatient services for women with heavy menstrual bleeding (HMB). In 2010, this study was conducted to provide an update on guideline-related services provided in England and Wales, and whether they are consistent with national clinical guidelines two to three years after publication.MethodsAn organisational survey of outpatient gynaecology clinics was conducted of 221 hospitals in 154 acute National Health Service (NHS) trusts in England and Wales. A questionnaire was distributed to all hospitals to examine provision of diagnostic and therapeutic services in outpatient settings. Descriptive statistics were used to summarize results.ResultsThe response rate was 100%. For diagnosis, 80% of hospitals had ultrasound, 87% had hysteroscopy, and 98% had endometrial biopsy available. Overall, 76% of hospitals provided an information leaflet, 8% referred patients to a website for information, and 20% did not provide any written information. A dedicated menstrual bleeding clinic was present in 38% of hospitals. Only 30% of hospitals reported that they have a local written protocol regarding the care and management of women with HMB.ConclusionThe majority of hospitals offer appropriate diagnostic and surgical services for women with HMB. However, local protocol development may not reflect the local services. It may be that hospitals are finding it difficult to summon resources to provide clinics for women with menstrual disorders.

Standards for radiological investigation of suspected non-accidental injury: a review of current practice

Background: Following publication of national guidelines regarding the investigation of non-accidental injury, a comprehensive review of local practice was completed (2008/09). We have revisited this with specific reference to follow up imaging and the addition of standards in neuroimaging and reporting.

Is point of care testing in Irish hospitals ready for the laboratory modernisation process? An audit against the current national Irish guidelines

The Laboratory modernisation process in Ireland will include point of care testing (POCT) as one of its central tenets. However, a previous baseline survey showed that POCT was under-resourced particularly with respect to information technology (IT) and staffing. An audit was undertaken to see if POCT services had improved since the publication of National Guidelines and if such services were ready for the major changes in laboratory medicine as envisaged by the Health Service Executive. The 15 recommendations of the 2007 Guidelines were used as a template for a questionnaire, which was distributed by the Irish External Quality Assessment Scheme. Thirty-nine of a possible 45 acute hospitals replied. Only a quarter of respondent hospitals had POCT committees, however, allocation of staff to POCT had doubled since the first baseline survey. Poor IT infrastructure, the use of unapproved devices, and low levels of adverse incident reporting were still major issues. Point of care testing remains under-resourced, despite the roll out of such devices throughout the health service including primary care. The present high standards of laboratory medicine may not be maintained if the quality and cost-effectiveness of POCT is not controlled. Adherence to national Guidelines and adequate resourcing is essential to ensure patient safety.

Management of chronic obstructive pulmonary disease in Australia after the publication of national guidelines

Information on the management of chronic obstructive pulmonary disease (COPD) in Australia, especially the extent of adherence to the COPD-X Plan, is sparse. To evaluate COPD patient adherence to treatment recommendations and healthcare provider adherence to the COPD-X Plan. Cross-sectional study of patients admitted to a secondary care hospital with an acute exacerbation of COPD over a 6-month period. Data were collected from patient interviews and medical notes. Participants (n= 45) aged 72 ± 11.5 years (mean ± SD) had a mean FEV(1) % predicted 52.2 ± 18.7. At the time 11 (24.4%) patients continued to smoke; 25 (55.6%) had never participated in a pulmonary rehabilitation programme; and 23 (51.1%) self-reported poor adherence to some COPD medications. Inhaler technique was deemed suboptimal in 25 (55.6%) patients. Only 11 (24.4%) patients had received any instructions from their doctor regarding management of exacerbations. The use of medications not supported by the COPD-X guidelines were: long-term prednisolone (11, 24.4%) and prophylactic antibiotics (3, 6.7%). Management of COPD in Australia by both patients and providers remains suboptimal despite the publication and wide dissemination of the COPD-X Plan, suggesting the need to intensify both patient and provider education in COPD management.

Discussion of emotional and social impact of cancer during outpatient oncology consultations

Following publication of national guidelines on detection and management of psychosocial problems in oncology, this study explores frequency of discussion of emotional and social issues in outpatient oncology consultations. Analysis of baseline data from 212 outpatients participating in a randomized controlled trial. Baseline data included content analysis of audio recordings of consultations, Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire subscale scores, and patient and clinician self-rated preferences and perceptions of communication. Fifty-nine percent patients and 75% clinicians expressed preferences to discuss emotional issues during consultations. Analysis of audio recordings showed that they were discussed in 27% of the consultations, regardless of severity of emotional problems reported by patients (FACT-G Emotional well-being subscale). Fifty percent of clinicians reported discussing emotional issues 'often' or 'almost always', compared with 18% of patients. Forty-four percent patients and 39% clinicians reported that they would discuss social activities, but they were actually discussed in 46% of consultations. Patients predominantly initiated discussion of emotional and social issues (85 and 60% consultations, respectively). Low prevalence of discussion of psychosocial issues cannot be accounted for by patient or clinician communication preferences. If clinicians rely on patients to initiate discussion of psychosocial issues, patients' problems may go unaddressed.

Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines*

To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation. Observational study. Pediatric intensive care unit of a university hospital. A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8), with spontaneous cardiac rhythm. Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed. After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35-40 torr, 4.6-5.3 kPa) in 70% of the cases upon arrival. Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.

Venous thrombosis prevention – more than just guidelines

Hospital-associated venous thromboembolism remains a major international cause of avoidable mortality and morbidity. Although the publication of national guidelines does increase the use of thromboprophylaxis, we present the results of a recent audit of thrombosis prevention in UK hospitals which, despite published guidelines, shows continuing significant variations in guideline implementation and practice. The results of this audit are paralleled with UK and international data on hospital-acquired thrombosis prevention and the potential solutions to these problems, particularly the lessons which can be learned from other areas of clinical practice, are discussed.

QUALITY OF SPIROMETRY DATA FROM PRIMARY CARE

PURPOSE: Following the publication of national guidelines on the management of chronic obstructive pulmonary disease in adults in primary and secondary care in 2004, there has been a steady rise in spirometry in primary care in the United Kingdom (UK), but little is known about the quality and understanding of the test in this setting.

Has the publication of methicillin-resistant Staphylococcus aureus (MRSA) treatment guidelines increased the survival associated with MRSA bacteraemia?

To establish whether local practice review and national methicillin-resistant Staphylococcus aureus (MRSA) treatment guidelines have increased the survival of patients with MRSA bacteraemia. A multisite retrospective analysis of survival of patients with MRSA bacteraemia, which included patients from March 1995 to December 2008. Periods before and after the publication of UK guidelines were compared. Data were analysed for 1675 patients with a mean age of 69.8 years. Survival for the period up to and including 2003 was 64.3%, and was 62.8% for both 2004-2005 and 2006-2008. No significant difference in survival in relation to local practice review or the publication of national guidelines was detected.

Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines

fective clinical management of STDs represent an important combined strategy necessary to improve reproductive and sexual health and to improve HIV prevention efforts. This is especially relevant to women, adolescents, and infants, because untreated infections frequently result in severe, long-term complications, including facilitation of HIV infection, tubal infertility, adverse pregnancy outcomes, and cancer. For >20 years, the publication of national guidelines by the Centers for Disease Control and Prevention