Practice Guidelines For Support Research Articles

The Quality of Evidence Supporting Clinical Practice Guidelines in General Surgery

This meta-analysis assesses the strength and quality of clinical recommendations in practice guidelines published by professional societies.

High Proportion of Low-Quality Evidence Underpin the Management of Adult Congenital Heart Disease: An Independent Review of the Level of Evidence Supporting Practice Guidelines

High Proportion of Low-Quality Evidence Underpin the Management of Adult Congenital Heart Disease: An Independent Review of the Level of Evidence Supporting Practice Guidelines

Generative AI enhanced with NCCN clinical practice guidelines for clinical decision support: A case study on bone cancer.

e13623 Background: Bone cancer is a complex and challenging disease to diagnose and treat in clinical practice. Recently, generative AI, especially large language models (LLMs), has demonstrated potential as a decision support tool for cancer. However, most implementations have overlooked the integration of available cancer guidelines, such as the NCCN Bone Cancer Guidelines, in fine-tuning the outputs of generative AI models. Incorporating these guidelines into LLMs presents an opportunity to harness the extensive clinical knowledge they contain and improve the decision-support capabilities of the model. Methods: In this study, the aim is to enhance the LLM with cancer clinical guidelines to enable accurate medical decisions and personalized treatment recommendations. Therefore, we introduce a novel method for incorporating the NCCN Bone Cancer Guidelines into LLMs using a Binary Decision Tree (BDT) approach. The approach involves constructing a BDT based on NCCN Bone Cancer Guidelines, where internal nodes represent decision points from the Guidelines, and leaf node signify final treatment suggestions. Then the LLM makes decision at each internal node, considering a given patient's characteristics, and guides toward a treatment recommendation in the leaf node. To assess the efficacy of Guideline-enhanced LLMs, an oncologist from our team created 11 hypothetical osteosarcoma patients’ medical progress notes. Each note contains their demographics, medical history, current illness, physical exams, diagnostic tests. We tested three LLMs in the implementation (GPT-4, GPT-3.5, and PaLM 2) and compared the LLM-generated treatment recommendations with the gold standard treatment across four runs with different random seeds (random seeds is a setting to control the LLM outputs). The results are reported as the average of four runs. The original LLMs are used as baseline methods for comparison. Results: The table below provides a comparison between the performance of original LLMs and those augmented with cancer guidelines for osteosarcoma treatment recommendations. We can observe that the PaLM 2 model demonstrated superior performance compared to its counterparts, underscoring the effectiveness of integrating cancer guidelines into LLMs for decision support. Conclusions: The clinical decision support capabilities of the LLMs are promising when enhanced by NCCN Bone Cancer Guidelines using our approach. To fully exhibit the potential of our proposed method as a clinical decision support tool, further investigation into other subtypes of bone cancer should be conducted in the future study. [Table: see text]

A single blinded, phase IV, adaptive randomised control trial to evaluate the safety of coadministration of seasonal influenza and COVID-19 vaccines (The FluVID study)

ObjectivesWe evaluated the frequency of moderate and severe adverse events following coadministration of seasonal influenza vaccine (SIV) versus placebo with COVID-19 vaccines among adults to support practice guidelines. MethodsFluVID is a participant-blinded, phase IV, randomised control trial. On the same day as the participant’s scheduled COVID-19 vaccine, participants were randomised to receive SIV or saline placebo; those assigned placebo at visit one then received SIV a week later, and vice versa. Self-reported adverse events were collected daily for seven days following each visit.The primary endpoint was any solicited adverse event of at least moderate severity occurring up to seven days following receipt of SIV or placebo. This was modelled using a Bayesian logistic regression model. Analyses were performed by COVID-19 vaccine type and dose number. ResultsOverall, 248 participants were enrolled; of these, 195 had received BNT162b2 and 53 had received mRNA1273 COVID-19 vaccines according to national guidelines. After randomisation, 119 were assigned to receive SIV and 129 were assigned to receive placebo at visit one.Adverse events were most frequently reported as mild (grade 1) in nature. Among 142 BNT162b2 booster dose one and 43 BNT162b2 booster dose two recipients, the posterior median risk difference for moderate/severe adverse events following SIV versus placebo was 13% (95% credible interval [CrI] −0.03 to 0.27) and 13% (95%CrI −0.37 to 0.12), respectively. Among 18 mRNA1273 booster dose one and 35 mRNA1273 booster dose two recipients, the posterior median risk difference of moderate/severe adverse events following influenza vaccine versus placebo was 6% (95%CrI −0.29 to 0.41) and −4% (95%CrI −0.30 to 0.23), respectively. ConclusionAdverse events following SIV and COVID-19 co-administration were generally mild and occurred with similar frequency to events following COVID-19 vaccine alone. We found no evidence to justify routine separation of SIV and COVID-19 vaccine doses.Clinical trial registration: ACTRN12621001063808.

US Military Healthcare Professionals' Practice, Knowledge, and Misconceptions About Concussion.

To determine the US military healthcare professionals' knowledge and training preferences to improve diagnosis and management of concussion sustained in nondeployed settings. US military healthcare professionals (physicians, physician assistants, and nurse practitioners) completed online surveys to investigate practices, knowledge, and attitudes about concussion diagnosis and treatment, as well as preferences on future training. There were 744 responses from active duty US military healthcare providers, all of whom had cared for at least one patient with mild traumatic brain injury (mTBI) in the previous 24 months. The majority of physicians reported they were confident in their ability to evaluate a patient for a new mTBI (82.1%) and order appropriate imaging for mTBI (78.3%). Accuracy of identifying "red flag" symptoms ranged between 28.2% and 92.6%. A Likert scale from 1 ("not at all confident") to 4 ("very confident") was used to assess providers' confidence in their ability to perform services for patients with mTBI. With respect to barriers to optimal patient care, nurse practitioners consistently reported highest levels of barriers (90.8%). Although US military providers regularly care for patients with concussion, many report experiencing barriers to providing care, low confidence in basic skills, and inadequate training to diagnose and manage these patients. Customized provider education based on branch of service and occupation, and broader dissemination and utilization of decision support tools or practice guidelines, and patient information tool kits could help improve concussion care.

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Acute Pancreatitis: Initial Treatment, Nutritional Support, Convalescent Treatment

Initial and convalescent treatment of acute pancreatitis (AP) is important in order to improve the prognosis and prevent the recurrence in the patients with AP. Initial intensive treatment includes fluid therapy, pain control, antimicrobial therapy, endoscopic retrograde cholangiopancreatography (ERCP), and nutritional support. Goal-directed therapy is recommended for fluid therapy, and the routine use of prophylactic antibiotics is not recommended. In acute gallstone pancreatitis, urgent ERCP should be performed only in patients with cholangitis or persistent cholestasis. Early oral feeding is advisable as tolerated and enteral feeding via nasogastric or nasojejunal tube appear comparable. In convalescent treatment, cholecystectomy during the initial admission is advisable for mild biliary pancreatitis with gallstone as possible, and treatment against alcohol dependence is considerable for recurrent acute alcoholic pancreatitis. In this review, we recommend practice guidelines for initial treatment, nutritional support, and convalescent treatment.

Implementation of vascular surgery teleconsultation during the COVID-19 pandemic: Insights from the outpatient vascular clinics in a tertiary care hospital in Qatar.

The COVID-19 pandemic has sparked a surge in the use of virtual communication tools for delivering clinical services for many non-urgent medical needs allowing telehealth or telemedicine, to become an almost inevitable part of the patient care. However, most of patients with vascular disease may require face-to-face interaction and are at risk of worse outcomes if not managed in timely manner. We aimed to describe the utilization of telemedicine services in the outpatient vascular surgery clinics in a tertiary hospital. A retrospective analysis of data on all vascular outpatient encounters during 2019 and 2020 was conducted and compared to reflect the pattern of practice prior to and during the COVID-19 pandemic. The study showed that 61% of the total patient encounters in 2020 were reported through teleconsultation. Females were the majority of patients who sought the virtual vascular care. Consultations for the new cases decreased from 29% to 26% whereas, the follow-up cases increased from 71% to 74% in 2020 (p = 0.001). The number of procedures performed in the vascular outpatient clinics decreased by 46% in 2020 when compared to 2019. This decrease in procedures was more evident in the duration from February 2020 to April 2020 in which the procedures decreased by 97%. The proportion of procedures represented 22.6% of the total encounters in 2019 and 10.5% of the encounters during 2020, (p = 0.001). Teleconsultation, along with supporting practice guidelines, can be used to maximize the efficiency of care in vascular surgery patients during the pandemic and beyond. Adoption of the 'hybrid care' which combines both virtual and in-person services as an ongoing practice requires evidence obtained through audits and studies on patients and healthcare providers levels. It is essential to establish a clear practice that ensures patient's needs.

Recommendations and Associated Levels of Evidence for Statin Use in Primary Prevention of Cardiovascular Disease: A Comparison at Population Level of the American Heart Association/American College of Cardiology/Multisociety, US Preventive Services Task Force, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society Clinical Practice Guidelines.

Despite using identical evidence to support practice guidelines for lipid-lowering treatment in primary prevention of cardiovascular disease (CVD), it is unclear to what extent the 2018 American Heart Association/American College of Cardiology/Multisociety, 2016 US Preventive Services Task Force (USPSTF), 2020 Department of Veterans Affairs/Department of Defense, 2021 Canadian Cardiovascular Society, and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines differ in grading and assigning levels of evidence and classes of recommendations (LOE/class) at a population level. We included 7262 participants, aged 45 to 75 years, without history of CVD from the prospective population-based Rotterdam Study. Per guideline, proportions of the population recommended statin therapy by LOE/class, sensitivity and specificity for CVD events, and numbers needed to treat at 10 years were calculated. Mean age was 61.1 (SD 6.9) years; 58.2% were women. American Heart Association/American College of Cardiology/Multisociety, USPSTF, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society strongly recommended statin initiation in respective 59.4%, 40.2%, 45.2%, 73.7%, and 42.1% of the eligible population based on high-quality evidence. Sensitivity for CVD events for treatment recommendations supported with strong LOE/class was 86.3% for American Heart Association/American College of Cardiology/Multisociety (IA or IB), 69.4% for USPSTF (USPSTF-B), 74.5% for Department of Veterans Affairs/Department of Defense (strong for), 93.3% for Canadian Cardiovascular Society (strong), and 66.6% for European Society of Cardiology/European Atherosclerosis Society (IA). Specificity was highest for the USPSTF at 45.3% and lowest for European Society of Cardiology/European Atherosclerosis Society at 10.0%. Estimated numbers needed to treat at 10 years for those with the strongest LOE/class were ranging from 20 to 26 for moderate-intensity and 12 to 16 for high-intensity statins. Sensitivity, specificity, and numbers needed to treat at 10 years for assigned LOE/class varied greatly among 5 CVD prevention guidelines. The level of variability seems to be driven by differences in how the evidence is graded and translated into LOE/class underlying the treatment recommendations by different professional societies. Efforts towards harmonizing evidence grading systems for clinical guidelines in primary prevention of CVD may reduce ambiguity and reinforce updated evidence-based recommendations.

Practice guidelines for peer support among educators during a curriculum innovation

Background. Curriculum transformation in nursing education addresses changing healthcare needs of communities. However, without ongoing support of educators, the fidelity of curriculum enactment could be compromised. Nursing education institutions in Lesotho implemented a competency-based curriculum that required novel pedagogical approaches. New facilitation approaches can challenge implementers, as was observed during the implementation of a new curriculum for the midwifery programme in Lesotho. Without ongoing faculty development and support, the educators resorted to supporting one another. However, the sustainability and effectiveness of the unstructured peer support could be compromised; hence the need to develop guidelines to enhance peer support among educators during curriculum innovation. Objective. To develop and validate guidelines to enhance peer support among educators during curriculum innovation. Methods. A qualitative research design with multiple data collection methods was conducted, guided by the World Health Organization Handbook for Guideline Development as the framework . Three interrelated phases, inclusive of an integrative review, an exploratory qualitative study, guideline development and validation, were conducted. External reviewers validated the developed guidelines by means of a Delphi survey. Results. Five priority areas were identified for the practice guidelines, i.e. attributes of peer supporters, peer support strategies, content/support needs, outcomes of peer support, and monitoring and evaluation of the peer support strategy. Recommendations were formulated for each priority area. Conclusion. These practice guidelines provide relevant recommendations that can enhance peer support among educators in nursing education programmes during curriculum innovation. The recommendations serve as a blueprint and provide direction for the structured peer support engagements.

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery.

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

Applying NASA Satellite Data to Examine Emerging One Health Threats: Going Beyond Traditional Epidemiologic Methods

Emerging environmental health threats, such as exposure to air pollutants, extreme temperatures, and infectious pathogens, directly affect human and animal health. These exposures can affect morbidity and mortality rates as a result of increased risk of developing acute or chronic illnesses. The World Health Organization has quantified the direct human impact of these environmental risks, including living or working in unhealthy environments (12.6 million deaths), vector-borne disease transmission (700,000 deaths), and ambient and household air pollution (6.5 million deaths). In order to advance future environmental health research applications and field interventions, traditional epidemiologic methods must be integrated with innovative approaches that encourage cross-cutting One Health topics and foster transdisciplinary collaborations. One innovative approach highlights the value of integrating NASA Earth-observing satellite data (e.g. chlorophyll, nitrogen dioxide, surface temperature, vegetation) into traditional research methods. Scientists and stakeholders can analyze these data of public health importance and examine associations between variables, identify disease or vector hotspots, and forecast real-time environmental exposure levels. These efforts can alert health authorities and inform their health decision-making for policy and public health recommendations. In this paper, we will define the One Health concept as a holistic view of environmental health research applications, as they relate to aquatic, atmospheric, and terrestrial ecosystems. We will describe the need to integrate innovative approaches to traditional epidemiologic methods and practices, focusing on the value of satellite data to closely examine the impact of an array of environmental exposures. We will present three examples that exemplify how satellite data can advance scientific knowledge, strengthen communication with stakeholders and decision-makers, and support policy decision-making and practice guidelines. These novel approaches have the potential to strengthen global health systems, foster innovation in environmental health research applications, and reinforce capacity building for the global health workforce.

Biomarkers for Traumatic Brain Injury: Data Standards and Statistical Considerations.

Recent biomarker innovations hold potential for transforming diagnosis, prognostic modeling, and precision therapeutic targeting of traumatic brain injury (TBI). However, many biomarkers, including brain imaging, genomics, and proteomics, involve vast quantities of high-throughput and high-content data. Management, curation, analysis, and evidence synthesis of these data are not trivial tasks. In this review, we discuss data management concepts and statistical and data sharing strategies when dealing with biomarker data in the context of TBI research. We propose that application of biomarkers involves three distinct steps-discovery, evaluation, and evidence synthesis. First, complex/big data has to be reduced to useful data elements at the stage of biomarker discovery. Second, inferential statistical approaches must be applied to these biomarker data elements for assessment of biomarker clinical utility and validity. Last, synthesis of relevant research is required to support practice guidelines and enable health decisions informed by the highest quality, up-to-date evidence available. We focus our discussion around recent experiences from the International Traumatic Brain Injury Research (InTBIR) initiative, with a specific focus on four major clinical projects (Transforming Research and Clinical Knowledge in TBI, Collaborative European NeuroTrauma Effectiveness Research in TBI, Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe, and Approaches and Decisions in Acute Pediatric TBI Trial), which are currently enrolling subjects in North America and Europe. We discuss common data elements, data collection efforts, data-sharing opportunities, and challenges, as well as examine the statistical techniques required to realize successful adoption and use of biomarkers in the clinic as a foundation for precision medicine in TBI.

Recommendations for the management of pediatric septic shock in the first hour (part one).

In the past two years, different organizations have updated their clinical practice guidelines for hemodynamic support in pediatric septic shock. The studies conducted in adults have questioned the initial management of sepsis in accordance to protocols based on achieving various goals. However, the usefulness of these protocols in children has been demonstrated. The possibility of adhering to guidelines may vary depending on patients and facilities, so it is necessary to update the general aspects of initial care for children with sepsis. The proposal is to shift the paradigm from an "individual practice guideline," which is universal for all, to an "institutional practice guideline" and to assess the factors that should be improved at each facility. This manuscript is divided into two parts. The first part analyzes the bundles for the early detection of septic shock. Part two addresses treatment, stabilization, referral, and process analysis.

Finding Fit: School Nurses Lead the Way in the Development of Employee Wellness Program.

School nurses are in a unique position to monitor and influence not only the health of students but also the health of school employees. The National Association of School Nurses (NASN) provides support and evidence-based best practice guidelines for the specialty practice of school nursing. NASN's Framework for 21st Century School Nursing Practice™ provides a road map for a healthy and safe school environment. With a focus on student health and academic success, the framework also aligns with the whole school, whole community, whole child model to provide a collaborative structure to learning and health. Both models are student centered and include family, the school community, and school employees. A group of school nurses from the Alexandria City Public Schools (ACPS) in Alexandria, Virginia, attended the Johnson and Johnson School Health Leadership Program and were challenged to create sustainable change in their community. Their goal was to develop a plan for the school division that would affect employee wellness and ultimately improve student achievement and educational outcomes. This article will describe the current ACPS Employee Wellness Program, Finding Fit, and the strategies and tools used to develop the program.

Surgical Outcome Comparison of Posterior Vertebral Column Resection with or without Anterior Column Support in Treatment of Yang’s Type A Severe Thoracic Spinal Deformity

The use of posterior vertebral column resection (PVCR) has extended the treatment of severe spinal deformity. However, the practice guidelines for anterior column support in patients treated by PVCR remain ill defined. The objective of the present study was to compare the clinical and radiographic outcomes of severe thoracic spinal deformity treated by PVCR with and without anterior column support (ACS). We performed a prospective study of 57 patients with severe thoracic deformity (classified as Yang's A type) treated by PVCR with or without anterior column support from January 2010 to April 2015. The patient characteristics, radiographic parameters, intraoperative data, and complications were analyzed to clarify these 2 clinical series. The sex, age, diagnosis, curve magnitude, and curve type were similar between the PVCR with ACS group (n= 21) and non-ACS group (n= 36) preoperatively. Evaluation of the radiographic parameters, intraoperative data, and complications found no statistically significant intergroup differences, except for the osteotomy distance (non-ACS group, 4.0 cm; ACS group, 5.3 cm; P < 0.001) and shortening distance of the osteotomy gap (non-ACS group, 4.0 cm; ACS group, 3.5 cm; P= 0.005). The results of the present study have shown that PVCR without ACS seems to be a safe and effective technique for Yang's A type severe thoracic spinal deformity correction compared with PVCR with ACS. PVCR without ACS requires a relatively smaller osteotomy range and could potentially decrease the risk of implant failure due to bone to bone fusion.

Nutrition Assessment, Exposures, and Interventions for Very-Low-Birth-Weight Preterm Infants: An Evidence Analysis Center Scoping Review

Annually, 15 million infants, or approximately 1 of every 10, are born before term, 1 Centers for Disease Control and Prevention. Preterm Birth 2017. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm. Accessed September 9, 2017. Google Scholar , 2 World Health Organization. Preterm Birth. http://www.who.int/mediacentre/factsheets/fs363/en/. Accessed September 6, 2017. Google Scholar leading to short- and long-term health consequences such as infection, growth concerns, developmental impairment, and other comorbidities. 3 Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press. https://doi.org/10.17226/11622. Accessed May 25, 2017. Google Scholar , 4 Platt M.J. Outcomes in preterm infants. Public Health. 2014; 128: 399-403 Crossref PubMed Scopus (123) Google Scholar Nutrition interventions may address some effects of prematurity. However, current, comprehensive, evidence-based nutrition practice guidelines (EBNPGs) for preterm infants are lacking in the literature. 5 Raiten D.J. Steiber A.L. Carlson S.E. et al. Working group reports: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 648S-678S Crossref PubMed Scopus (24) Google Scholar , 6 Raiten D.J. Steiber A.L. Hand R.K. Executive summary: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 599S-605S Crossref PubMed Scopus (20) Google Scholar Existing guidelines for preterm infants are not based on comprehensive systematic reviews (SRs) and may not represent the current population of preterm infants seen in the neonatal intensive care unit (NICU), which include smaller and less developmentally mature infants. 5 Raiten D.J. Steiber A.L. Carlson S.E. et al. Working group reports: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 648S-678S Crossref PubMed Scopus (24) Google Scholar In addition, treatment options for preterm infants are continually evolving, and current guidelines must address relevant practices in the NICU. L. Moloney is nutrition researcher at the Academy of Nutrition and Dietetics, Chicago, IL. M. Rozga is nutrition researcher at the Academy of Nutrition and Dietetics, Chicago, IL. T. R. Fenton is nutrition research lead, Nutrition Services, Alberta Health Services, and associate professor, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding?

The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.

Cancer Symptom Management by Radiation Therapists: Factors Influencing Use of Evidence-Informed Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) Practice Guides

To identify the barriers and facilitators influencing radiation therapists (MRTs) and registered nurses (RNs) use of the pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides for supporting patients experiencing symptoms from radiation therapy. A mixed-methods study guided by the Knowledge to Action Framework. The study was conducted in a large radiation therapy department in Ontario where on average 6000 radiation treatments are administered per month. A survey was sent to all MRTs and RNs who provide direct care to patients. Interviews were conducted with 14 MRTs and 3 RNs using a semi-structured interview guide. Quantitative data from the survey was analyzed descriptively and qualitative data from the interviews were analyzed through thematic content analysis by two independent reviewers. Of 100 distributed surveys, 72 were completed (72% response rate) by 58 MRTs, 11 RNs, and 3 did not report their discipline. The survey indicated that 98.3% MRTs and 100% of RNs provide symptom support to clients with cancer. However, only 53.4% of MRTs and 81.8% of RNs use evidence-informed practice guidelines for symptom support. For the survey items, MRTs had moderate moral norms (4.6 out of 7) and beliefs about consequences of using COSTaRS practice guides (4.8) but neutral intention (3.4) and beliefs about their capabilities (3.9), and low social influence (1.8). RNs had high moral norms (5.6), beliefs about consequences of using COSTaRS (5.7), and beliefs about capabilities (5.8), moderately high intentions to use them (5.3), and moderate social influence (4.0). Environmental barriers for MRTs included lack of time (2.0), lack of access (2.5), and neutral for support from the organization (3.0) and colleagues (3.2). MRTs identified the need for training (5.5). RNs indicated having adequate access (5.6) and organizational support to use COSTaRS (5.7) with some support from colleagues (4.6). There was still a need for some additional training (4.0) and some concern about not having enough time to use them (3.3). Common barriers identified in the interviews included lack of time during the radiation treatments, symptoms outside of MRT scope of practice and lack of medication knowledge, preference to escalate to nursing, need for integration with electronic documentation, long and overwhelming guides, and preventing extra time for patients who value efficiency. Common facilitators were comprehensive and evidence-based guides, clear organizational mandate of expectations for use, need to fit with current workflow and documentation, and the daily interaction between MRTs and patients. Overall, COSTaRS practice guides were recognized as being high quality resources to support symptom management. Interventions to overcome barriers to using them were education and training, strong leadership support, fit with workflow of MRT activities, integration with documentation, and easy accessibility.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines?

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m2 and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".