Full Text Available Abstract Background Practice guidelines can improve health care delivery and outcomes but several issues challenge guideline adoption, including their intrinsic attributes, and whether and how they are implemented. It appears that guideline format may influence accessibility and ease of use, which may overcome attitudinal barriers of guideline adoption, and appear to be important to all stakeholders. Guideline content may facilitate various forms of decision making about guideline adoption relevant to different stakeholders. Knowledge and attitudes about, and incentives and capacity for implementation on the part of guideline sponsors may influence whether and how they develop guidelines containing these features, and undertake implementation. Examination of these issues may yield opportunities to improve guideline adoption. Methods The attributes hypothesized to facilitate adoption will be expanded by thematic analysis, and quantitative and qualitative summary of the content of international guidelines for two primary care (diabetes, hypertension and institutional care (chronic ulcer, chronic heart failure topics. Factors that influence whether and how guidelines are implemented will be explored by qualitative analysis of interviews with individuals affiliated with guideline sponsoring agencies. Discussion Previous research examined guideline implementation by measuring rates of compliance with recommendations or associated outcomes, but this produced little insight on how the products themselves, or their implementation, could be improved. This research will establish a theoretical basis upon which to conduct experimental studies to compare the cost-effectiveness of interventions that enhance guideline development and implementation capacity. Such studies could first examine short-term outcomes predictive of guideline utilization, such as recall, attitude toward, confidence in, and adoption intention. If successful, then long-term objective
Masekela, Belinda; Nienaber, Rita
To attain and sustain a competitive advantage organizations are continually faced with the need to change their structures, processes and technologies. Converting to new technology and implementing a new information management system in an organization results in inevitable changes in organizational procedures impacting on the people involved. A major problem encountered during this process is resistance to change, which may contribute to total failure of this system. Change management is the process that can be used to negate this impact and assist employees in transitioning to a new way of doing things.
Guidelines were introduced in hospital and practice-based otorhinolaryngology in the 1990s, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. The Society has cooperated in a further 34 guidelines. The quality of the guidelines has been continually improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.]. Since increasing digitalisation has made access to scientific publications quicker and more simple, relevant study results can be incorporated in guidelines more easily today than in the analogue world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines. © Georg Thieme Verlag KG Stuttgart · New York.
Richter-Sundberg, Linda; Kardakis, Therese; Weinehall, Lars; Garvare, Rickard; Nyström, Monica E
Many of the world's life threatening diseases (e.g. cancer, heart disease, stroke) could be prevented by eliminating life-style habits such as tobacco use, unhealthy diet, physical inactivity and excessive alcohol use. Incorporating evidence-based research on methods to change unhealthy lifestyle habits in clinical practice would be equally valuable. However gaps between guideline development and implementation are well documented, with implications for health care quality, safety and effectiveness. The development phase of guidelines has been shown to be important both for the quality in guideline content and for the success of implementation. There are, however, indications that guidelines related to general disease prevention methods encounter specific barriers compared to guidelines that are diagnosis-specific. In 2011 the Swedish National board for Health and Welfare launched guidelines with a preventive scope. The aim of this study was to investigate how implementation challenges were addressed during the development process of these disease preventive guidelines. Seven semi-structured interviews were conducted with members of the guideline development management group. Archival data detailing the guideline development process were also collected and used in the analysis. Qualitative data were analysed using content analysis as the analytical framework. The study identified several strategies and approaches that were used to address implementation challenges during guideline development. Four themes emerged from the analysis: broad agreements and consensus about scope and purpose; a formalized and structured development procedure; systematic and active involvement of stakeholders; and openness and transparency in the specific guideline development procedure. Additional factors concerning the scope of prevention and the work environment of guideline developers were perceived to influence the possibilities to address implementation issues. This case study
Full Text Available BACKGROUND: Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines. METHODS: Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data. RESULTS: 2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time. CONCLUSION: There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted.
Alanen, Seija; Välimäki, Marita; Kaila, Minna
AIMS: The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? BACKGROUND: The implementation of clinical guidelines seems...... to be dependent on multiple context-specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. DESIGN: Qualitative interview. METHODS: Data were generated by four focus group interviews involving nurses working in out-patient services in primary...... to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses' awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines...
Full Text Available Abstract Background Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care. Methods This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data. Results The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1 organizational resources, (2 health care professionals' individual characteristics and (3 perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1 concerns about control over professional practice, (2 beliefs about evidence-based practice and (3 suspicions about financial motives for guideline introduction. Conclusions Identifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify
Redaèlli, Marcus; Vollmar, Horst Christian; Simic, Dusan; Maly-Schürer, Cornelia; Löscher, Susanne; Koneczny, Nikolaus
Knowledge transfer from theory to practice in healthcare systems poses a challenge worldwide. Typical examples include national disease management guidelines. The present study contributes towards improving implementation strategies for an asthma guideline. A guideline implementation strategy was examined in a four-armed, non-randomised, controlled intervention study with an additional control group. The study participants were general practitioners and paediatricians recruited from primary care quality circles. All study participants attended an interactive seminar on the evidence-based recommendations for patients with asthma. In addition, the participants were asked to choose among the following options: no further intervention, additional e-learning, training of their practice nurses, or e-learning and training of their practice nurses. The success of the intervention was measured by questionnaire (and the success rate expressed as a percentage). About one third of all participants (n=313) opted for the combination of an interactive seminar and a training of practice nurses; two third preferred the classic way of continuing medical education with an interactive seminar without a further intervention. Just 10 % of the physicians participated in e-learning. Independently of their choice for continuing medical education, all participants demonstrated an increase in knowledge about asthma and an improvement in the management of asthma. The physicians exhibited an average increase in both categories of about 10 % of the percentage values, compared to an increase of about 28 % among the practice nurses without continuing medical education. The physicians' free choice of the educative modules might be an integral part of successful implementation strategies. However, this will require a change of focus from general continuing medical education packages to a more individualised culture of continuing professional development in Germany. Copyright © 2015. Published by
Hermens, Marleen L M; Oud, Matthijs; Sinnema, Henny; Nauta, Maaike H; Stikkelbroek, Yvonne; van Duin, Daniëlle; Wensing, Michel
It is important that depressed patients receive adequate and safe care as described in clinical guidelines. The aim of this study was to evaluate the implementation of the Dutch depression guideline for children and adolescents, and to identify factors that were associated with the uptake of the
Donnellan, Claire; Sweetman, S; Shelley, E
Clinical guidelines are frequently used as a mechanism for implementing evidence-based practice. However research indicates that health professionals vary in the extent to which they adhere to these guidelines. This study aimed to study the perceptions of stakeholders and health professionals on the facilitators and barriers to implementing national stroke guidelines in Ireland. Qualitative interviews using focus groups were conducted with stakeholders (n=3) and multidisciplinary team members from hospitals involved in stroke care (n=7). All focus group interviews were semi-structured, using open-ended questions. Data was managed and analysed using NVivo 9 software. The main themes to emerge from the focus groups with stakeholders and hospital multidisciplinary teams were very similar in terms of topics discussed. These were resources, national stroke guidelines as a tool for change, characteristics of national stroke guidelines, advocacy at local level and community stroke care challenges. Facilitators perceived by stakeholders and health professionals included having dedicated resources, user-friendly guidelines relevant at local level and having supportive advocates on the ground. Barriers were inadequate resources, poor guideline characteristics and insufficient training and education. This study highlights health professionals' perspectives regarding many key concepts which may affect the implementation of stroke care guidelines. The introduction of stroke clinical guidelines at a national level is not sufficient to improve health care quality as they should be incorporated in a quality assurance cycle with education programmes and feedback from surveys of clinical practice. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Waldorff, Frans Boch; Almind, Gert; Mäkelä, Marjukka
OBJECTIVE: To assess the impact of a multifaceted implementation strategy aiming to improve GP adherence to a clinical guideline on dementia. DESIGN: Controlled before and after study using data records from regional laboratories. The guideline was mailed to all GPs. The multifaceted implementation...... strategy was planned with local GPs, and consisted of seminars, outreach visits, reminders and continuing medical education (CME) small group training. SETTING: Primary health care. SUBJECTS: 535 GP practices with 727 physicians in Denmark. MAIN OUTCOME MEASURES: The diffusion and use of the guideline...... of dementia in general practice. CONCLUSION: Although GPs regarded the guideline applicable in primary care, no change in practice adherence to guideline recommendations was detected after a multifaceted implementation....
van Dijk Maarten K
Full Text Available Abstract Background Recent years have seen the large-scale development of clinical practice guidelines for mental disorders in several countries. In the Netherlands, more than ten multidisciplinary guidelines for mental health care have been developed since 2003. The first dealt with the treatment of anxiety disorders. An important question was whether it is feasible to implement these guidelines because implementing practice guidelines is often difficult. Although several implementation interventions have proven effective, there seems to be no ready-made strategy that works in all circumstances. Case description The Dutch multidisciplinary guidelines for anxiety disorders were implemented in a community mental health care centre, located in the east of the Netherlands. The centre provides secondary outpatient care. The unit within the centre that specializes in the treatment of anxiety disorders has 16 team members with diverse professional backgrounds. Important steps in the process of implementing the guidelines were analysing the care provided before start of the implementation to determine the goals for improvement, and analysing the context and target group for implementation. Based on these analyses, a tailor-made multifaceted implementation strategy was developed that combined the reorganization of the care process, the development of instruction materials, the organization of educational meetings and the use of continuous quality circles to improve adherence to guidelines. Discussion and evaluation Significant improvements in adherence rates were made in the aspect of care that was targeted for change. An increase was found in the number of patients being provided with recommended forms of psychotherapeutic treatment, ranging from 43% to 54% (p Conclusion The case study presented here shows that the implementation of practice guidelines for anxiety disorders in mental health care is feasible. Based on the results of our study, the
Schmidt, Anders S; Lauridsen, Kasper G; Adelborg, Kasper; Løfgren, Bo
This study aimed to investigate cardiopulmonary resuscitation (CPR) guideline implementation and CPR training in hospitals. This nationwide study included mandatory resuscitation protocols from each Danish hospital. Protocols were systematically reviewed for adherence to the European Resuscitation Council (ERC) 2010 guidelines and CPR training in each hospital. Data were included from 45 of 47 hospitals. Adherence to the ERC basic life support (BLS) algorithm was 49%, whereas 63 and 58% of hospitals adhered to the recommended chest compression depth and rate. Adherence to the ERC advanced life support (ALS) algorithm was 81%. Hospital BLS course duration was [median (interquartile range)] 2.3 (1.5-2.5) h, whereas ALS course duration was 4.0 (2.5-8.0) h. Implementation of ERC 2010 guidelines on BLS is limited in Danish hospitals 2 years after guideline publication, whereas the majority of hospitals adhere to the ALS algorithm. CPR training differs among hospitals.
Hermens, Marleen L M; Oud, Matthijs; Sinnema, Henny; Nauta, Maaike H; Stikkelbroek, Yvonne; van Duin, Daniëlle; Wensing, Michel
It is important that depressed patients receive adequate and safe care as described in clinical guidelines. The aim of this study was to evaluate the implementation of the Dutch depression guideline for children and adolescents, and to identify factors that were associated with the uptake of the guideline recommendations. The study took place in specialised child and adolescent mental healthcare. An implementation project was initiated to enhance the implementation of the guideline. An evaluation study was performed alongside the implementation project, using structured registration forms and interviews with healthcare professionals. Six multidisciplinary teams participated in the implementation study. The records of 655 patients were analysed. After 1 year, 72% of all eligible patients had been screened for depression and 38% were diagnosed with the use of a diagnostic instrument. The severity of the depression was assessed in 77% of the patients during the diagnostic process, and 41% of the patients received the recommended intervention based on the depression severity. Of the patients that received antidepressants, 25% received weekly checks for suicidal thoughts in the first 6 weeks. Monitoring of the patients' response was recorded in 32% of the patients. A wide range of factors were perceived to influence the uptake of guideline recommendations, e.g. the availability of capable professionals, available time, electronic tools and reminders, and the professionals' skills and attitudes. With the involvement of the teams, recommendations were provided for nationwide implementation of the guideline. In conclusion, a systematic implementation programme using stepped care principles for the allocation of depression interventions seems successful, but there remains room for further improvement.
Girlanda, Francesca; Fiedler, Ines; Becker, Thomas; Barbui, Corrado; Koesters, Markus
Clinical practice guidelines are not easily implemented, leading to a gap between research synthesis and their use in routine care. To summarise the evidence relating to the impact of guideline implementation on provider performance and patient outcomes in mental healthcare settings, and to explore the performance of different strategies for guideline implementation. A systematic review of randomised controlled trials, controlled clinical trials and before-and-after studies comparing guideline implementation strategies v. usual care, and different guideline implementation strategies, in patients with severe mental illness. In total, 19 studies met our inclusion criteria. The studies did not show a consistent positive effect of guideline implementation on provider performance, but a more consistent small to modest positive effect on patient outcomes. Guideline implementation does not seem to have an impact on provider performance, nonetheless it may influence patient outcomes positively. © The Royal College of Psychiatrists 2017.
Milisen, Koen; Coussement, Joke; Arnout, Hanne; Vanlerberghe, Virginie; De Paepe, Leen; Schoevaerdts, Didier; Lambert, Margareta; Van Den Noortgate, Nele; Delbaere, Kim; Boonen, Steven; Dejaeger, Eddy
About 40% of all adverse events in hospital are falls, but only about one in three Belgian hospitals have a fall prevention policy in place. The implementation of a national practice guideline is urgently needed. This multicentre study aimed to determine the feasibility of a previously developed guideline. SETTING, PARTICIPANTS AND METHOD: Seventeen geriatric wards, selected at random out of 40 Belgian hospitals who agreed to take part in the study, evaluated the fall prevention guideline. After the one-month test period, 49 healthcare workers completed a questionnaire on the feasibility of the guideline. At the end of the study, 512 geriatric patients had been assessed using the practice guideline. The average time spent per patient on case finding, multifactorial assessment and initiating a treatment plan was 5.1, 76.1 and 30.6 min, respectively. For most risk assessments and risk modifications, several disciplines considered themselves as being responsible and capable. The majority (more than 69%) of the respondents judged the practice guideline as useful, but only a small majority (62.3%) believed that the guideline could be successfully integrated into their daily practice over a longer period of time. Barriers for implementation included a large time investment (81.1%), lack of communication between the different disciplines (35.8%), lack of motivation of the patient (34.0%), lack of multidisciplinary teamwork (28.3%), and lack of interest from the hospital management (15.4%). Overall, the guideline was found useful, and for each risk factor (except for visual impairment), at least one discipline felt responsible and capable. Towards future implementation of the guideline, following steps should be considered: division of the risk-factor assessment duties and interventions among different healthcare workers; patient education; appointment of a fall prevention coordinator; development of a fall prevention policy with support from the management of the hospital
Waldorff, Frans Boch; Almind, Gert; Mäkelä, Marjukka
OBJECTIVE: To assess the impact of a multifaceted implementation strategy aiming to improve GP adherence to a clinical guideline on dementia. DESIGN: Controlled before and after study using data records from regional laboratories. The guideline was mailed to all GPs. The multifaceted implementation...... strategy was planned with local GPs, and consisted of seminars, outreach visits, reminders and continuing medical education (CME) small group training. SETTING: Primary health care. SUBJECTS: 535 GP practices with 727 physicians in Denmark. MAIN OUTCOME MEASURES: The diffusion and use of the guideline...... was measured by a mailed survey. Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient's > or = 65 years: thyroid stimulating hormone requested with vitamin B12 or methylmalonate. The use of these tests as part of a diagnostic evaluation of dementia...
Stærk, Mathilde; Glerup Lauridsen, Kasper; Mygind-Klausen, Troels
Introduction: Implementation of guidelines into clinical practice is important to provide quality of care. Implementation of clinical guidelines is known to be poor. This study aimed to investigate awareness, expected time frame and strategy for implementation of the European Resuscitation Council...... 2015 and time frame and strategy for implementation.Results: In total, 41 hospitals replied (response rate: 87%) between October 22nd and December 22nd 2015. Overall, 37% of hospital resuscitation committees were unaware of the content of the guidelines. The majority of hospitals (80%) expected...... completion of guideline implementation within 6 months and 93% of hospitals expected the staff to act according to the ERC Guidelines 2015 within 6 months. In contrast, 78% of hospitals expected it would take between 6 months to 3 years for all staff to have completed a resuscitation course based on ERC...
Vest, Bonnie M; York, Trevor R M; Sand, Jessica; Fox, Chester H; Kahn, Linda S
Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. © Copyright 2015 by the American Board of Family Medicine.
Le, Jette V; Hansen, Helle P; Riisgaard, Helle; Lykkegaard, Jesper; Nexøe, Jørgen; Bro, Flemming; Søndergaard, Jens
Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP's decision on whether and how to manage implementation. Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
McCluskey, Annie; Vratsistas-Curto, Angela; Schurr, Karl
Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005). Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists
Goldberg, Judith L
Performing proper hand hygiene and surgical hand antisepsis is essential to reducing the rates of health care-associated infections, including surgical site infections. The updated AORN "Guideline for hand hygiene" provides guidance on hand hygiene and surgical hand antisepsis, the wearing of fingernail polish and artificial nails, proper skin care to prevent dermatitis, the wearing of jewelry, hand hygiene product selection, and quality assurance and performance improvement considerations. This article focuses on key points of the guideline to help perioperative personnel make informed decisions about hand hygiene and surgical hand antisepsis. The key points address the necessity of keeping fingernails and skin healthy, not wearing jewelry on the hands or wrists in the perioperative area, properly performing hand hygiene and surgical hand antisepsis, and involving patients and visitors in hand hygiene initiatives. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Rashidian, Arash; Eccles, Martin P; Russell, Ian
We aimed to explore key themes for the implementation of guidelines' prescribing recommendations. We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis. Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid 'evidence'. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs' perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely. GPs were critical of guidelines' development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.
Full Text Available Abstract Background Antihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing. Methods In this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31, a doctor-nurse pair was trained to act as peer facilitators in the intervention. All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes. Results In all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR was 1.12 (95% CI 0.99, 1.25; p = 0.06 and for controls 1.13 (1.05, 1.21; p = 0.002. We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004 and controls OR 1.24 (1.15, 1.34; p Conclusions A multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.
van Bodegom-Vos, Leti; Verhoef, John; Dickmann, Margot; Kleijn, Marjon; van Vliet, Ingrid; Hurkmans, Emalie; van der Wees, Philip; Vliet Vlieland, Thea
Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied. Objectives The objective of this study was to identify the similarities and differences in barriers to the implementation of a Dutch rheumatoid arthritis (RA) guideline by generalist and specialist physical therapists. Design This observational study consisted of 4 focus group interviews in which 24 physical therapists (13 generalist and 11 specialist physical therapists) participated. Physical therapists were asked to discuss barriers to the implementation of the RA guideline. Data were analyzed qualitatively using a directed approach to content analysis. Both the interviews and the interview analysis were informed by a previously developed conceptual framework. Besides a number of similarities (eg, lack of time), the present study showed important, although subtle, differences in barriers to the implementation of the RA guideline between generalist physical therapists and specialist physical therapists. Generalist physical therapists more frequently reported difficulties in interpreting the guideline (cognitive barriers) and had less favorable opinions about the guideline (affective barriers) than specialist physical therapists. Specialist physical therapists were hampered by external barriers that are outside the scope of generalist physical therapists, such as a lack of agreement about the roles and responsibilities of medical professionals involved in the care of the same patient. The identified differences in barriers to the implementation of the RA guideline indicated that the effectiveness of implementation strategies could be improved by tailoring them to the level of specialization of physical therapists. However, it is expected that tailoring implementation strategies to barriers that hamper both generalist
Coman, Ovidiu; Samaddar, Sujit; Hibino, Kenta; )
The presentation was devoted to development of guidelines for implementation of a seismic PSA. If successful, these guidelines can close an important gap. ASME/ANS PRA standards and the related IAEA Safety Guide (IAEA NS-G-2.13) describe capability requirements for seismic PSA in order to support risk-informed applications. However, practical guidance on how to meet these requirements is limited. Such guidelines could significantly contribute to improving risk-informed safety demonstration, safety management and decision making. Extensions of this effort to further PSA areas, particularly to PSA for other external hazards, can enhance risk-informed applications
Paquay, Louis; Verstraete, Sabine; Wouters, Renild; Buntinx, Frank; Vanderwee, Katrien; Defloor, Tom; Van Gansbeke, Hendrik
To investigate the effect of the implementation of a patient and family education programme for pressure ulcer prevention in an organisation for home care nursing on guideline adherence and on prevalence and severity of pressure ulcers and to examine the determining factors for the application of measures for pressure ulcer prevention. Quality improvement programmes in pressure ulcer prevention are not always successful. Implementation study using a pretest-post-test design. Data were collected in three probability samples. The first post-test data collection was held after six months, the second after 18 months. Statistical analysis was used, comparing the pretest sample and the second post-test sample. After 18 months, the proportion of subjects with adherent measures had increased from 10·4-13·9%, the proportion of subjects with non-adherent measures decreased from 45·7-36·0%, the proportion of subjects without pressure ulcer prevention increased from 43·9-50·1% (ppressure ulcer prevalence and less severe skin lesions. The nurses' judgement of a patient risk status was the most important factor for applying preventive measures. Furthermore, application of pressure ulcer prevention was determined by higher age (from the age category of 70-79 years), higher dependency for the activities of daily living, higher than baseline mobility score and the presence of a pressure ulcer. Guideline adherence in pressure ulcer prevention changed significantly after implementation of the education programme. There might have been inconsistencies in the nurses' risk judgement. Quality of pressure ulcer prevention improved, but several items for improvement remain. Adaptation of risk assessment procedures is needed. © 2010 Blackwell Publishing Ltd.
Zaboli, Rouhollah; Tofighi, Shahram; Aghighi, Ali; Shokouh, Seyyed Javad Hosaini; Naraghi, Nader; Goodarzi, Hassan
Clinical practice guidelines are structured recommendations that help physicians and patients to make proper decisions when dealing with a specific clinical condition. Because blunt abdominal trauma causes a various range of mild, single-system, and multisystem injuries, early detection will help to reduce mortality and resulting disability. Emergency treatment should be initiated based on CPGs. This study aimed to determine the variables affecting implementing blunt abdominal trauma CPGs in an Iranian hospital. This study was conducted as a qualitative and phenomenology study in the Family Hospital in Tehran (Iran) in 2015. The research population included eight experts and key people in the area of blunt abdominal trauma clinical practice guidelines. Sampling was based on purposive and nonrandom methods. A semistructured interview was done for the data collection. A framework method was applied for the data analysis by using Atlas.ti software. After framework analyzing and various reviewing and deleting and combining the codes from 251 codes obtained, 15 families and five super families were extracted, including technical knowledge barriers, economical barriers, barriers related to deployment and monitoring, political will barriers, and managing barriers. Structural reform is needed for eliminating the defects available in the healthcare system. As with most of the codes, subconcepts and concepts are classified into the field of human resources; it seems that the education and knowledge will be more important than other resources such as capital and equipment.
... 10 Energy 4 2010-01-01 2010-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...
Full Text Available Background The electronic medical records software of the Catalan Institute of Health has recently incorporated an electronic version of clinical practice guidelines (e-CPGs. This study aims to assess the impact of the implementation of e-CPGs on the diagnosis, treatment, control and management of hypercholesterolaemia, diabetes mellitus type 2 and hypertension.Methods Eligible study participants are those aged 35–74 years assigned to family practitioners (FPs of the Catalan Institute of Health. Routinely collected data from electronic primary care registries covering 80% of the Catalan population will be analysed using two approaches: (1 a cross-sectional study to describe the characteristics of the sample before e-CPG implementation; (2 a controlled before-and-after study with 1-year follow-up to ascertain the effect of e-CPG implementation. Patients of FPs who regularly use the e-CPGs will constitute the intervention group; the control group will comprise patients assigned to FPs not regularly using the e-CPG. The outcomes are: (1 suspected and confirmed diagnoses, (2 control of clinical variables, (3 requests for tests and (4 proportions of patients with adequate drug prescriptions.Results This protocol should represent a reproducible process to assess the impact of the implementation of e-CPGs. We anticipate reporting results in late 2013.Conclusion This project will assess the effectiveness of e-CPGs to improve clinical decisions and healthcare procedures in the three disorders analysed. The results will shed light on the use of evidence-based medicine to improve clinical practice of FPs.
Full Text Available Abstract Background Despite strong evidence of the benefits of preconception interventions for improving pregnancy outcomes, the delivery and uptake of preconception care and periconceptional folate supplementation remain low. General practitioners play a central role in the delivery of preconception care. Understanding general practitioners’ perceptions of the barriers and enablers to implementing preconception care allows for more appropriate targeting of quality improvement interventions. Consequently, the aim of this study was to examine the barriers and enablers to the delivery and uptake of preconception care guidelines from general practitioners’ perspective using theoretical domains related to behaviour change. Methods We conducted a qualitative study using focus groups consisting of 22 general practitioners who were recruited from three regional general practice support organisations. Questions were based on the theoretical domain framework, which describes 12 domains related to behaviour change. General practitioners’ responses were classified into predefined themes using a deductive process of thematic analysis. Results Beliefs about capabilities, motivations and goals, environmental context and resources, and memory, attention and decision making were the key domains identified in the barrier analysis. Some of the perceived barriers identified by general practitioners were time constraints, the lack of women presenting at the preconception stage, the numerous competing preventive priorities within the general practice setting, issues relating to the cost of and access to preconception care, and the lack of resources for assisting in the delivery of preconception care guidelines. Perceived enablers identified by general practitioners included the availability of preconception care checklists and patient brochures, handouts, and waiting room posters outlining the benefits and availability of preconception care consultations
Girlanda, Francesca; Fiedler, Ines; Ay, Esra; Barbui, Corrado; Koesters, Markus
Clinical practice guidelines in mental healthcare are viewed as an essential asset if appropriately developed and implemented. The purpose of this article was to review the existing literature on how guidelines should be implemented to optimize their impact on provider performance and patient outcomes in specialist mental healthcare settings. Findings from recent studies suggest a trend toward an improvement in process and patient outcomes following guideline implementation. However, studies are heterogeneous in terms of design, implementation strategies and outcome measures, making it very difficult to draw firm conclusions about which implementation strategy is effective in different healthcare contexts. Current knowledge about how guidelines should be implemented is still sparse and inconclusive in mental healthcare. Future studies should attempt to employ more rigorous designs, including random allocation of patients or clusters of patients, to shed further light on this compelling issue. Research on guideline implementation strategies should additionally take into account potential barriers to knowledge translation, which can heavily influence the implementability of treatment recommendations.
Scott Shannon D
Full Text Available Abstract Background Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT. Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased healthcare costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve KT and reduce clinical practice variation. Design/Methods Using a multiple case study design, qualitative and quantitative data will be collected from four emergency departments in western Canada. Data sources will include: pre- and post-implementation focus group data from multidisciplinary healthcare professionals; individual interviews with the local champions, KT intervention providers, and unit/site leaders/managers; Alberta Context Tool (ACT survey data; and aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated, and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the clinical practice guidelines (CPG and clinical pathways (CPs uptake based upon the cross-case comparisons. Significance This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.
Vrancken, A.F.J.E.; Kalmijn, S.; Buskens, E.; Franssen, H.; Wokke, J.H.J.; Notermans, N.C.
Background: Extensive investigations are often performed to reveal the cause of chronic polyneuropathy. It is not known whether a restrictive diagnostic guideline improves cost efficiency without loss of diagnostic reliability. Methods: In a prospective multicentre study, a comparison was made
Full Text Available Abstract Background Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. However, there is evidence that the nutritional intake of older people living in care homes is suboptimal, with high levels of saturated fat, salt, and added sugars. The UK Food Standards Agency therefore developed nutrient- and food-based guidance for residential care homes. The acceptability of these guidelines and their feasibility in practice is unknown. This study used the Normalization Process Theory (NPT to understand the barriers and facilitators to implementing the guidelines and inform future implementation. Methods We conducted a process evaluation in five care homes in the north of England using qualitative methods (observation and interviews to explore the views of managers, care staff, catering staff, and domestic staff. Data were analyzed thematically and discussed in data workshops; emerging themes were then mapped to the constructs of NPT. Results Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people. In terms of NPT, the guidelines simply did not make sense (coherence, and as a result, relatively few staff invested in the guidelines (cognitive participation. Even where staff supported the guidelines, implementation was hampered by a lack of nutritional knowledge and institutional support (collective action. Finally, the absence of observable benefits to clients confirmed the negative preconceptions of many staff, with limited evidence of reappraisal following implementation (reflexive monitoring. Conclusions The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed. Specialist support is needed to equip staff with the technical knowledge and skills required for menu analysis and development and to
Bodegom-Vos, L. van; Verhoef, J.; Dickmann, M.; Kleijn, M.; van Vliet, I.; Hurkmans, E.; Wees, P.J. van der; Vliet Vlieland, T.
BACKGROUND: Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied. Objectives The objective of this study
Gagliardi Anna R
Full Text Available Abstract Background Guidelines are important tools that inform healthcare delivery based on best available research evidence. Guideline use is in part based on quality of the guidelines, which includes advice for implementation and has been shown to vary. Others hypothesized this is due to limited instructions in guideline development manuals. The purpose of this study was to examine manual instructions for implementation advice. Methods We used a directed and summative content analysis approach based on an established framework of guideline implementability. Six manuals identified by another research group were examined to enumerate implementability domains and elements. Results Manuals were similar in content but lacked sufficient detail in particular domains. Most frequently this was Accomodation, which includes information that would help guideline users anticipate and/or overcome organizational and system level barriers. In more than one manual, information was also lacking for Communicability, information that would educate patients or facilitate their involvement in shared decision making, and Applicability, or clinical parameters to help clinicians tailor recommendations for individual patients. Discussion Most manuals that direct guideline development lack complete information about incorporating implementation advice. These findings can be used by those who developed the manuals to consider expanding their content in these domains. It can also be used by guideline developers as they plan the content and implementation of their guidelines so that the two are integrated. New approaches for guideline development and implementation may need to be developed. Use of guidelines might be improved if they included implementation advice, but this must be evaluated through ongoing research.
Vrancken, A. F. J. E.; Kalmijn, S.; Buskens, E.; Franssen, H.; Vermeulen, M.; Wokke, J. H. J.; Notermans, N. C.
Extensive investigations are often performed to reveal the cause of chronic polyneuropathy. It is not known whether a restrictive diagnostic guideline improves cost efficiency without loss of diagnostic reliability. In a prospective multicentre study, a comparison was made between the workup in
Haycock, Ken; Cavill, Pat
This case study examined: (1) what market research is required for planning for the implementation of "Information Power: Building Partnerships for Learning," the 1998 national guidelines for effective school library media programs; (2) what issues need to be addressed and what target audiences are required to effect change, as well as…
Full Text Available Abstract Background Although considerable efforts are directed at developing international guidelines to improve clinical management in low-income settings they appear to influence practice rarely. This study aimed to explore barriers to guideline implementation in the early phase of an intervention study in four district hospitals in Kenya. Methods We developed a simple interview guide based on a simple characterisation of the intervention informed by review of major theories on barriers to uptake of guidelines. In-depth interviews, non-participatory observation, and informal discussions were then used to explore perceived barriers to guideline introduction and general improvements in paediatric and newborn care. Data were collected four to five months after in-service training in the hospitals. Data were transcribed, themes explored, and revised in two rounds of coding and analysis using NVivo 7 software, subjected to a layered analysis, reviewed, and revised after discussion with four hospital staff who acted as within-hospital facilitators. Results A total of 29 health workers were interviewed. Ten major themes preventing guideline uptake were identified: incomplete training coverage; inadequacies in local standard setting and leadership; lack of recognition and appreciation of good work; poor communication and teamwork; organizational constraints and limited resources; counterproductive health worker norms; absence of perceived benefits linked to adoption of new practices; difficulties accepting change; lack of motivation; and conflicting attitudes and beliefs. Conclusion While the barriers identified are broadly similar in theme to those reported from high-income settings, their specific nature often differs. For example, at an institutional level there is an almost complete lack of systems to introduce or reinforce guidelines, poor teamwork across different cadres of health worker, and failure to confront poor practice. At an individual
Kang, Min-Koo; Kim, Byung-Keun; Kim, Tae-Wan; Kim, Sae-Hoon; Kang, Hye-Ryun; Park, Heung-Woo; Chang, Yoon-Seok; Kim, Sun-Sin; Min, Kyung-Up; Kim, You-Young; Cho, Sang-Heon
Patient care based on asthma guidelines is cost-effective and leads to improved treatment outcomes. However, ineffective implementation strategies interfere with the use of these recommendations in clinical practice. This study investigated physicians' preferences for asthma guidelines, including content, supporting evidence, learning strategies, format, and placement in the clinical workplace. We obtained information through a questionnaire survey. The questionnaire was distributed to physicians attending continuing medical education courses and sent to other physicians by airmail, e-mail, and facsimile. A total of 183 physicians responded (male to female ratio, 2.3:1; mean age, 40.4±9.9 years); 89.9% of respondents were internists or pediatricians, and 51.7% were primary care physicians. Physicians preferred information that described asthma medications, classified the disease according to severity and level of control, and provided methods of evaluation/treatment/monitoring and management of acute exacerbation. The most effective strategies for encouraging the use of the guidelines were through continuing medical education and discussions with colleagues. Physicians required supporting evidence in the form of randomized controlled trials and expert consensus. They preferred that the guidelines be presented as algorithms or flow charts/flow diagrams on plastic sheets, pocket cards, or in electronic medical records. This study identified the items of the asthma guidelines preferred by physicians in Korea. Asthma guidelines with physicians' preferences would encourage their implementation in clinical practice.
Gutiérrez-Alba, Gaudencio; González-Block, Miguel Ángel; Reyes-Morales, Hortensia
To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.
Gagliardi Anna R
Full Text Available Abstract Background Modifying the format and content of guidelines may facilitate their use and lead to improved quality of care. We reviewed the medical literature to identify features desired by different users and associated with guideline use to develop a framework of implementability and found that most guidelines do not contain these elements. Further research is needed to develop and evaluate implementability tools. Methods We are launching the Guideline Implementability Research and Application Network (GIRAnet to enable the development and testing of implementability tools in three domains: Resource Implications, Implementation, and Evaluation. Partners include the Guidelines International Network (G-I-N and its member guideline developers, implementers, and researchers. In phase one, international guidelines will be examined to identify and describe exemplar tools. Indication-specific and generic tools will populate a searchable repository. In phase two, qualitative analysis of cognitive interviews will be used to understand how developers can best integrate implementability tools in guidelines and how health professionals use them for interpreting and applying guidelines. In phase three, a small-scale pilot test will assess the impact of implementability tools based on quantitative analysis of chart-based behavioural outcomes and qualitative analysis of interviews with participants. The findings will be used to plan a more comprehensive future evaluation of implementability tools. Discussion Infrastructure funding to establish GIRAnet will be leveraged with the in-kind contributions of collaborating national and international guideline developers to advance our knowledge of implementation practice and science. Needs assessment and evaluation of GIRAnet will provide a greater understanding of how to develop and sustain such knowledge-exchange networks. Ultimately, by facilitating use of guidelines, this research may lead to improved
Diehl, Heinz; Graverholt, Birgitte; Espehaug, Birgitte
-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE. RESULTS: Five cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation...
Schmutz, Sven; Sonderegger, Andreas; Sauer, Juergen
The present study examined whether implementing recommendations of Web accessibility guidelines would have different effects on nondisabled users than on users with visual impairments. The predominant approach for making Web sites accessible for users with disabilities is to apply accessibility guidelines. However, it has been hardly examined whether this approach has side effects for nondisabled users. A comparison of the effects on both user groups would contribute to a better understanding of possible advantages and drawbacks of applying accessibility guidelines. Participants from two matched samples, comprising 55 participants with visual impairments and 55 without impairments, took part in a synchronous remote testing of a Web site. Each participant was randomly assigned to one of three Web sites, which differed in the level of accessibility (very low, low, and high) according to recommendations of the well-established Web Content Accessibility Guidelines 2.0 (WCAG 2.0). Performance (i.e., task completion rate and task completion time) and a range of subjective variables (i.e., perceived usability, positive affect, negative affect, perceived aesthetics, perceived workload, and user experience) were measured. Higher conformance to Web accessibility guidelines resulted in increased performance and more positive user ratings (e.g., perceived usability or aesthetics) for both user groups. There was no interaction between user group and accessibility level. Higher conformance to WCAG 2.0 may result in benefits for nondisabled users and users with visual impairments alike. Practitioners may use the present findings as a basis for deciding on whether and how to implement accessibility best.
These Guidelines were designed by the Energy Quality Council to help managers and supervisors in the Department of Energy Complex bring Total Quality Management to their organizations. Because the Department is composed of a rich mixture of diverse organizations, each with its own distinctive culture and quality history, these Guidelines are intended to be adapted by users to meet the particular needs of their organizations. For example, for organizations that are well along on their quality journeys and may already have achieved quality results, these Guidelines will provide a consistent methodology and terminology reference to foster their alignment with the overall Energy quality initiative. For organizations that are just beginning their quality journeys, these Guidelines will serve as a startup manual on quality principles applied in the Energy context.
Ferreira de Meneses, Sarah; Rannou, Francois; Hunter, David J
Osteoarthritis (OA) is a leading cause of disability worldwide. Clinical practice guidelines (CPGs) have been developed to facilitate improved OA management. Scientific communities worldwide have proposed CPGs for OA treatment. Despite the number of highly prominent guidelines available and their remarkable consistency, their uptake has been suboptimal. Possibly because of the multitude of barriers related to the implementation of CPGs. For example, different guidelines show contradictions, some lack evidence, and they lack a hierarchy or tools to facilitate their translation and application. Also, the guidelines do not acknowledge the effect of comorbidities on choosing the treatments. Finally, poor integration of multidisciplinary services within and across healthcare settings is a major barrier to the effective implementation of management guidelines. Here we describe the main problems related to the OA guidelines and some solutions so as to offer some guidance on the elaboration of future CPGs and their implementation in primary care. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Dogherty Elizabeth J
Full Text Available Abstract Background Facilitation is emerging as an important strategy in the uptake of evidence. However, it is not entirely clear from a practical perspective how facilitation occurs to help move research evidence into nursing practice. The Canadian Partnership Against Cancer, also known as the 'Partnership,' is a Pan-Canadian initiative supporting knowledge translation activity for improved care through guideline use. In this case-series study, five self-identified groups volunteered to use a systematic methodology to adapt existing clinical practice guidelines for Canadian use. With 'Partnership' support, local and external facilitators provided assistance for groups to begin the process by adapting the guidelines and planning for implementation. Methods To gain a more comprehensive understanding of the nature of facilitation, we conducted a mixed-methods study. Specifically, we examined the role and skills of individuals actively engaged in facilitation as well as the actual facilitation activities occurring within the 'Partnership.' The study was driven by and builds upon a focused literature review published in 2010 that examined facilitation as a role and process in achieving evidence-based practice in nursing. An audit tool outlining 46 discrete facilitation activities based on results of this review was used to examine the facilitation noted in the documents (emails, meeting minutes, field notes of three nursing-related cases participating in the 'Partnership' case-series study. To further examine the concept, six facilitators were interviewed about their practical experiences. The case-audit data were analyzed through a simple content analysis and triangulated with participant responses from the focus group interview to understand what occurred as these cases undertook guideline adaptation. Results The analysis of the three cases revealed that almost all of the 46 discrete, practical facilitation activities from the literature were
The overall objective of this thesis is to assess how guideline implementation and evaluation contribute to health care decision-making and to assess what critical factors contribute to successful or unsuccessful implementation of TB control guidelines through case studies mainly conducted in
Narayanaswami, Pushpa; Gronseth, Gary; Dubinsky, Richard; Penfold-Murray, Rebecca; Cox, Julie; Bever, Christopher; Martins, Yolanda; Rheaume, Carol; Shouse, Denise; Getchius, Thomas S D
Evidence-based clinical practice guidelines (CPGs) are statements that provide recommendations to optimize patient care for a specific clinical problem or question. Merely reading a guideline rarely leads to implementation of recommendations. The American Academy of Neurology (AAN) has a formal process of guideline development and dissemination. The last few years have seen a burgeoning of social media such as Facebook, Twitter, and LinkedIn, and newer methods of dissemination such as podcasts and webinars. The role of these media in guideline dissemination has not been studied. Systematic evaluation of dissemination methods and comparison of the effectiveness of newer methods with traditional methods is not available. It is also not known whether specific dissemination methods may be more effectively targeted to specific audiences. Our aim was to (1) develop an innovative dissemination strategy by adding social media-based dissemination methods to traditional methods for the AAN clinical practice guidelines "Complementary and alternative medicine in multiple sclerosis" ("CAM in MS") and (2) evaluate whether the addition of social media outreach improves awareness of the CPG and knowledge of CPG recommendations, and affects implementation of those recommendations. Outcomes were measured by four surveys in each of the two target populations: patients and physicians/clinicians ("physicians"). The primary outcome was the difference in participants' intent to discuss use of complementary and alternative medicine (CAM) with their physicians or patients, respectively, after novel dissemination, as compared with that after traditional dissemination. Secondary outcomes were changes in awareness of the CPG, knowledge of CPG content, and behavior regarding CAM use in multiple sclerosis (MS). Response rates were 25.08% (622/2480) for physicians and 43.5% (348/800) for patients. Awareness of the CPG increased after traditional dissemination (absolute difference, 95% confidence
Losina, Elena; Smith, Savannah R; Usiskin, Ilana M; Klara, Kristina M; Michl, Griffin L; Deshpande, Bhushan R; Yang, Heidi Y; Smith, Karen C; Collins, Jamie E; Katz, Jeffrey N
We designed and implemented the Brigham and Women's Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees. We enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently. B-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently. Our data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial. Clinicaltrials.gov, NCT02850094
Full Text Available Abstract Background Recreational facilities are an important community resource for health promotion because they provide access to affordable physical activities. However, despite their health mandate, many have unhealthy food environments that may paradoxically increase the risk of childhood obesity. The Alberta Nutrition Guidelines for Children and Youth (ANGCY are government-initiated, voluntary guidelines intended to facilitate children’s access to healthy food and beverage choices in schools, childcare and recreational facilities, however few recreational facilities are using them. Methods We used mixed methods within an exploratory multiple case study to examine factors that influenced adoption and implementation of the ANGCY and the nature of the food environment within three cases: an adopter, a semi-adopter and a non-adopter of the ANGCY. Diffusion of Innovations theory provided the theoretical platform for the study. Qualitative data were generated through interviews, observations, and document reviews, and were analysed using directed content analysis. Set theoretic logic was used to identify factors that differentiated adopters from the non-adopter. Quantitative sales data were also collected, and the quality of the food environment was scored using four complementary tools. Results The keys to adoption and implementation of nutrition guidelines in recreational facilities related to the managers’ nutrition-related knowledge, beliefs and perceptions, as these shaped his decisions and actions. The manager, however, could not accomplish adoption and implementation alone. Intersectoral linkages with schools and formal, health promoting partnerships with industry were also important for adoption and implementation to occur. The food environment in facilities that had adopted the ANGCY did not appear to be superior to the food environment in facilities that had not adopted the ANGCY. Conclusions ANGCY uptake may continue to falter
Balbale, Salva N; Hill, Jennifer N; Guihan, Marylou; Hogan, Timothy P; Cameron, Kenzie A; Goldstein, Barry; Evans, Charlesnika T
To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released. Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide. The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions. Successful
Gilbert, T.L.; Eckerman, K.F.; Hansen, W.R.; Healy, J.W.; Kennedy, W.E.; Napier, B.A.; Solday, J.K.
The US Department of Energy (DOE) has recently issued guidelines for residual radioactivity at Formerly Utilized Sites Remedial Action Program (FUSRAP) and remote Surplus Facilities Management Program (SFMP) sites. A manual for implementing these guidelines has been prepared jointly by four DOE laboratories (ANL, LANL, ORNL, and PNL) and is being issued as a supplement to the guidelines. The manual presents procedures and tables for deriving site-specific guidelines for levels of residual radionuclide concentrations in soil that must not be exceeded if a site is to be released for unrestricted use. Guidance for implementing DOE ALARA policy for remedial actions is also included. The concentration factor method is used in the pathway analysis for deriving soil guidelines. The analysis has been structured in a manner that explicitly identifies all of the factors involved. Tables are provided for dose-conversion factors and pathway factors from which environmental transport factors for each radionuclide and pathway may be calculated. The scenarios used for deriving the environmental transport factors and dose conversion factors, and the manner in which the information provided in the manual is used to derive site-specific soil guidelines will be presented
Pearson, Elizabeth J M; Morris, Meg E; McKinstry, Carol E
Cancer-related fatigue (CRF) is a key concern for people living with cancer and can impair physical functioning and activities of daily living. Evidence-based guidelines for CRF are available, yet inconsistently implemented globally. This study aimed to identify barriers and enablers to applying a cancer fatigue guideline and to derive implementation strategies. A mixed-method study explored the feasibility of implementing the CRF guideline developed by the Canadian Association for Psychosocial Oncology (CAPO). Health professionals, managers and consumers from different practice settings participated in a modified Delphi study with two survey rounds. A reference group informed the design of the study including the surveys. The first round focused on guideline characteristics, compatibility with current practice and experience, and behaviour change. The second survey built upon and triangulated the first round. Forty-five health practitioners and managers, and 68 cancer survivors completed the surveys. More than 75% of participants endorsed the CAPO cancer related fatigue guidelines. Some respondents perceived a lack of resources for accessible and expert fatigue management services. Further barriers to guideline implementation included complexity, limited practical details for some elements, and lack of clinical tools such as assessment tools or patient education materials. Recommendations to enhance guideline applicability centred around four main themes: (1) balancing the level of detail in the CAPO guideline with ease of use, (2) defining roles of different professional disciplines in CRF management, (3) how best to integrate CRF management into policy and practice, (4) how best to ensure a consumer-focused approach to CRF management. Translating current knowledge on optimal management of CRF into clinical practice can be enhanced by the adoption of valid guidelines. This study indicates that it is feasible to adopt the CAPO guidelines. Clinical application may
Powell, C; Maskell, G; Marks, M; South, M; Robertson, C; LENNEY, W.
AIMS—To develop and implement an evidence based guideline for the treatment of acute asthma using a metered dose inhaler and spacer combination. METHODS—Defined strategies were used for the development and implementation of a guideline, assessed by a prospective, descriptive, study using notes review, and patient, nursing, and medical staff telephone contact. The setting was a tertiary referral hospital in Victoria, Australia with 25 000 yearly admissions, and asthma acco...
Bain, Emily; Bubner, Tanya; Ashwood, Pat; Van Ryswyk, Emer; Simmonds, Lucy; Reid, Sally; Middleton, Philippa; Crowther, Caroline A
Strong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks' gestation to prevent very preterm babies dying or developing cerebral palsy. This study was undertaken as part of The WISH (Working to Improve Survival and Health for babies born very preterm) Project, to assess health professionals' self-reported use of antenatal magnesium sulphate, and barriers and enablers to implementation of 2010 Australian and New Zealand clinical practice guidelines. Semi-structured, one-to-one interviews were conducted with obstetric and neonatal consultants and trainees, and midwives in 2011 (n = 24) and 2012-2013 (n = 21) at the Women's and Children's Hospital, South Australia. Transcribed interview data were coded using the Theoretical Domains Framework (describing 14 domains related to behaviour change) for analysis of barriers and enablers. In 2012-13, health professionals more often reported 'routinely' or 'sometimes' administering or advising their colleagues to administer magnesium sulphate for fetal neuroprotection (86% in 2012-13 vs. 46% in 2011). 'Knowledge and skills', 'memory, attention and decision processes', 'environmental context and resources', 'beliefs about consequences' and 'social influences' were key domains identified in the barrier and enabler analysis. Perceived barriers were the complex administration processes, time pressures, and the unpredictability of preterm birth. Enablers included education for staff and women at risk of very preterm birth, reminders and 'prompts', simplified processes for administration, and influential colleagues. This study has provided valuable data on barriers and enablers to implementing magnesium sulphate for fetal neuroprotection, with implications for designing and modifying future behaviour change strategies, to ensure optimal uptake of this neuroprotective therapy for very preterm infants.
Teunissen, E; Gravenhorst, K; Dowrick, C; Van Weel-Baumgarten, E; Van den Driessen Mareeuw, F; de Brún, T; Burns, N; Lionis, C; Mair, F S; O'Donnell, C; O'Reilly-de Brún, M; Papadakaki, M; Saridaki, A; Spiegel, W; Van Weel, C; Van den Muijsenbergh, M; MacFarlane, A
Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice. We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers' fieldwork reports, were coded and thematically analysed by each team using NPT. In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants' needs. Implementation of interpreter services was difficult mainly because of financial and other
Full Text Available Abstract Background Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications was not assessed at all. Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing. The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers. Methods Two phase mixed methods design is proposed (ISRCTN 12345678. Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers will evaluate differences in outcomes between two implementation strategies. Primary outcome: Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations. Intervention: In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a printed materials, b one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c three post-workshop teleconferences. Discussion This
Alanen, Seija; Ijäs, Jarja; Kaila, Minna
RATIONALE, AIMS AND OBJECTIVES: Evidence-based guidelines on hypertension have been developed in many western countries. Yet, there is little evidence of their impact on the clinical practices of primary care nurses. METHOD: We assessed the style of implementation and adoption of the national...... Hypertension Guideline (HT Guideline) in 32 Finnish health centres classified in a previous study as 'disseminators' (n = 13) or 'implementers' (n = 19). A postal questionnaire was sent to all nurses (n = 409) working in the outpatient services in these health centres. Additionally, senior nursing officers...... were telephoned to enquire if the implementation of the HT Guideline had led to a new division of labour between nurses and doctors. RESULTS: Questionnaires were returned from 327 nurses (80.0%), while all senior nursing officers (n = 32) were contacted. The majority of nurses were of the opinion...
Full Text Available Abstract Background The use of oral anticoagulant therapy (OAT to prevent non-valvular atrial fibrillation (NVAF related-strokes is often sub-optimal. We aimed to evaluate whether implementing guidelines on antithrombotic therapy (AT by a multifaceted strategy may improve appropriateness of its prescription in NVAF-patients discharged from a large tertiary-care hospital. Methods A survey was conducted on all consecutive NVAF patients discharged before (1st January–30th June 2000, n = 313 and after (1st January–30th June 2004, n = 388 guideline development and implementation. Results When strongly recommended, OAT use increased from 56.6% (60/106 in 2000 to 81.9% (86/105 in 2004, with an absolute difference of +25.3% (95%CI: 15% 35%. In patients for whom the choice OAT/acetylsalicylic acid should be individualised, those discharged without any AT were 33.7% (34/101 in 2000 and 16.9% (21/124 in 2004 (-16.7%;95%CI: -26.2% -7.2%. In a logistic regression model, OAT prescription in 2004 was increased by 2.11 times (95%CI: 1.47 3.04, after accounting for stroke risk, presence of contraindications (OR = 0.18; 0.13 0.27, older age (OR = 0.30; 0.21 0.45, prophylaxis at admission (OR = 3.03; 2.08 4.43. OAT was positively associated with the stroke risk in the 2004 sample only. Conclusion The guideline implementation has substantially improved the appropriateness of OAT at discharge, through a better evaluation at patient's individual level of the benefit-to-risk ratio.
Burgers, J.A.; Kunst, P.W.; Koolen, M.G.; Willems, L.N.; Burgers, J.S.
The aim of the present study was to evaluate the implementation of the 2003 Dutch guideline on the diagnosis and treatment of malignant pleural effusions, and the potential effect of the implementation on the clinical outcome of pleurodesis. All patients with malignant pleural effusion who had a
Burgers, J. A.; Kunst, P. W. A.; Koolen, M. G. J.; Willems, L. N. A.; Burgers, J. S.; van den Heuvel, M.
The aim of the present study was to evaluate the implementation of the 2003 Dutch guideline on the diagnosis and treatment of malignant pleural effusions, and the potential effect of the implementation on the clinical outcome of pleurodesis. All patients with malignant pleural effusion who had a
Full Text Available (1 Background: In 2011, new chronic disease guidelines were introduced across Mongolia. No formal advice was provided regarding role delineation. This study aimed to analyse the roles that different primary care providers adopted, and the variations in these, in the implementation of the guidelines in urban Mongolia; (2 Methods: Ten group interviews with nurses and ten individual interviews each with practice doctors and practice directors were conducted. Data was analysed using a thematic approach based on the identified themes relevant to role delineation; (3 Results: There was some variability and flexibility in role delineation. Factors involving teamwork, task rotation and practice flexibility facilitated well the guideline implementation. However, factors including expectations and decision making, nursing shortage, and training gaps adversely influenced in the roles and responsibilities. Some role confusion and dissatisfaction was identified, often associated with a lack of training or staff turnover; (4 Conclusions: Findings suggest that adequate ongoing training is required to maximize the range of roles particular provider types, especially primary care nurses, are competent to perform. Ensuring that role delineation is specified in guidelines could remove confusion and enhance implementation of such guidelines.
Kim, Young-Min; Lee, Seung Joon; Jo, Sun Jin; Park, Kyu Nam
Objectives To identify the barriers to and facilitators of implementing guidelines for targeted temperature management (TTM) after cardiac arrest perceived by hospital resuscitation champions and to investigate the changes in their perceptions over the early implementation period. Design A longitudinal qualitative study (up to 2 serial semistructured interviews over 1 year and focus groups). The individual interviews and focus groups were transcribed and coded by 2 independent assessors. Contents were analysed thematically; group interaction was also examined. Setting 21 hospitals, including community and tertiary care centres in South Korea. Participants 21 hospital champions (14 acting champions and 7 managerial champions). Results The final data set included 40 interviews and 2 focus groups. The identified barriers and facilitators could be classified into 3 major themes: (1) healthcare professionals’ perceptions of the guidelines and protocols, (2) interdisciplinary and interprofessional collaboration and (3) organisational resources. Lack of resources was the most commonly agreed on barrier for the acting champions, whereas lack of interdisciplinary collaboration was the most common barrier for the managerial champions. Educational activities and sharing successfully treated cases were the most frequently identified facilitators. Most of the participants identified and agreed that cooling equipment was an important barrier as well as a facilitator of successful TTM implementation. Perception of the guidelines and protocols has improved with the accumulation of clinical experience over the study period. Conclusions Healthcare professionals’ internal barriers to TTM implementation may be influenced by new guidelines and can be changed with the accumulation of successful clinical experiences during the early implementation period. Promoting interprofessional and interdisciplinary collaboration through educational activities and the use of cooling equipment
...-01] RIN 0648-ZC19 Coral Reef Conservation Program Implementation Guidelines AGENCY: National Oceanic... Guidelines (Guidelines) for the Coral Reef Conservation Program (CRCP or Program) under the Coral Reef... assistance for coral reef conservation projects under the Act. NOAA revised the Implementation Guidelines for...
A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: a novel implementation strategy for adopting clinical guidelines for Opioid prescribing in primary care.
Quanbeck, Andrew; Brown, Randall T; Zgierska, Aleksandra E; Jacobson, Nora; Robinson, James M; Johnson, Roberta A; Deyo, Brienna M; Madden, Lynn; Tuan, Wen-Jan; Alagoz, Esra
This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named "systems consultation" aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels. We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques. Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: "I am more familiar with guidelines for safe opioid prescribing" and "My clinic's workflow for opioid prescribing is easier." At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were
Moreno, Eliana María; Moriana, Juan Antonio
There has been a considerable proliferation of clinical guidelines recently, but their practical application is low, and organisations do not always implement their own ones. The aim of this study is to analyse and describe key elements of strategies and resources designed by the National Institute for Health and Care Excellence for the implementation of guidelines for common mental health disorders in adults, which are some of the most prevalent worldwide. A systematic review was performed following PRISMA model. Resources, tools and implementation materials where included and categorised considering type, objectives, target and scope. A total of 212 elements were analysed, of which 33.5 and 24.5% are related to the implementation of generalized anxiety and depression guidelines, respectively. Applied tools designed to estimate costs and assess the feasibility of the setting up at local level are the most frequent type of resource. The study highlights the important variety of available materials, classified into 3 main strategies: tools targeting the professionals (30.6%), structural (26.4%), and organizational (24%). Developing guidelines is not enough; it is also necessary to promote their implementation in order to encourage their application. The resources and strategies described in this study may be potentially applicable to other contexts, and helpful to public health managers and professionals in the design of programmes and in the process of informed decision making to help increase access to efficient treatments. Copyright © 2015. Published by Elsevier España.
Emond, Yvette E J J M; Calsbeek, Hiske; Teerenstra, Steven; Bloo, Gerrit J A; Westert, Gert P; Damen, Johan; Wolff, André P; Wollersheim, Hub C
This study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed. This is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is
Harris Mark F
Full Text Available Abstract Background There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. Methods We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20% and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%; and lifestyle and physiological risk factors of patients at risk (by 5%. Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. Discussion We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.
Mengolini, A.; Debarberis, L.
This paper presents the methodology applied and the results achieved in adapting and implementing the IAEA guidelines on safety culture to a research reactor as a step towards supporting its Life Management Program. The background is presented together with the effort undertaken to develop awareness on safety culture and the enhancement programme hereafter developed. The present study shows how issues of safety culture, management awareness and commitment deserve attention and can be of fundamental relevance also for research reactors. The study presents how guidelines developed specifically for nuclear power installations (NPPs) can be adapted to meet the needs and peculiarities of other nuclear installations. Moreover, the difficulties met during the implementation of the guidelines are discussed and important information and lessons can be learnt for the nuclear industry in general
Diehl, Heinz; Graverholt, Birgitte; Espehaug, Birgitte; Lund, Hans
Research on guideline implementation strategies has mostly been conducted in settings which differ significantly from a nursing home setting and its transferability to the nursing home setting is therefore limited. The objective of this study was to systematically review the effects of interventions to improve the implementation of guidelines in nursing homes. A systematic literature search was conducted in the Cochrane Library, CINAHL, Embase, MEDLINE, DARE, HTA, CENTRAL, SveMed + and ISI Web of Science from their inception until August 2015. Reference screening and a citation search were performed. Studies were eligible if they evaluated any type of guideline implementation strategy in a nursing home setting. Eligible study designs were systematic reviews, randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE. Five cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation strategies. One study reported a small statistically significant effect on professional practice, and two studies demonstrated small to moderate statistically significant effects on patient outcome. The overall quality of the evidence for all comparisons was low or very low using GRADE. Little is known about how to improve the implementation of guidelines in nursing homes, and the evidence to support or discourage particular interventions is inconclusive. More implementation research is needed to ensure high quality of care in nursing homes. PROSPERO 2014: CRD42014007664.
Holleman, G.J.M.; Tol, M. van; Schoonhoven, L.; Groot, J. de; Achterberg, T. van
Employing nurses as opinion leaders to implement guidelines may be a promising implementation activity. Until now, insight into necessary competencies of nurse opinion leaders is lacking. We studied and supported aspiring nurse opinion leaders, using a training program based on social influence and
Tabbers, M.M.; Boluyt, N.; Offringa, M.
There is little experience with the nationwide implementation of an evidence-based pediatric guideline on first-choice fluid for resuscitation in hypovolemia. We investigated fluid prescribing behavior at (1) guideline development, (2) after guideline development, and (3) after active implementation
Hermens, M.L.M.; van Splunteren, P.T.; van den Bosch, A.; Verheul, R.
Objective: This study determined the gap between actual care and optimal care (recommended in the clinical guideline) for patients with borderline personality disorder in the Netherlands. Factors that affected guideline implementation were identified. Methods: Ten specialized mental health
Basic, I.; Krajnc, B.; Bilic-Zabric, T.; Spiler, J.
Severe Accident Management is a framework to identify and implement the Emergency Response Capabilities that can be used to prevent or mitigate severe accidents and their consequences. The USA NRC has indicated that the development of a licensee plant specific accident management program will be required in order to close out the severe accident regulatory issue (Ref. SECY-88-147). Generic Letter 88-20 ties the Accident management Program to IPE for each plant. The SECY-89-012 defines those actions taken during the course of an accident by the plant operating and technical staff to: 1) prevent core damage, 2) terminate the progress of core damage if it begins and retain the core within the reactor vessel, 3) maintain containment integrity as long as possible, and 4) minimize offsite releases. The subject of this paper is to document the severe accident management activities, which resulted in a plant specific Severe Accident Management Guidelines implementation. They have been developed based on the Krsko IPE (Individual Plant Examination) insights, Generic WOG SAMGs (Westinghouse Owners Group Severe Accident Management Guidances) and plant specific documents developed within this effort. Among the required plant specific actions the following are the most important ones: Identification and documentation of those Krsko plant specific severe accident management features (which also resulted from the IPE investigations). The development of the Krsko plant specific background documents (Severe Accident Plant Specific Strategies and SAMG Setpoint Calculation). Also, paper discusses effort done in the areas of NPP Krsko SAMG review (internal and external ), validation on Krsko Full Scope Simulator (Severe Accident sequences are simulated by MAAP4 in real time) and world 1st IAEA Review of Accident Management Programmes (RAMP). (author)
Teunissen, E.; Gravenhorst, K.; Dowrick, C.; Weel-Baumgarten, E.M. van; Driessen Mareeuw, F.A. van den; Brun, T. de; Burns, N.; Lionis, C.; Mair, F.S.; O'Donnell, C.; O'Reilly-de Brún, M.P.; Papadakaki, M.; Saridaki, A.; Spiegel, W.; Weel, C. van; Muijsenbergh, M.E.T.C. van den; Macfarlane, A.
BACKGROUND: Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this
Burgers, J A; Kunst, P W A; Koolen, M G J; Willems, L N A; Burgers, J S; van den Heuvel, M
The aim of the present study was to evaluate the implementation of the 2003 Dutch guideline on the diagnosis and treatment of malignant pleural effusions, and the potential effect of the implementation on the clinical outcome of pleurodesis. All patients with malignant pleural effusion who had a pleural drain placed with the intention of performing pleurodesis were registered prospectively in four centres. Details of the procedure and fluid recurrence and survival data were noted. Patients with a proven malignancy (n = 100) were entered into the registration database. Diagnostic guideline recommendations were followed in 60-70% of the patients. Surprisingly, pleurodesis was performed in only 75% of the patients, mainly due to the presence of a trapped lung. All pleurodeses were performed using talc, according to the guideline. Follow-up revealed fluid recurrence in 27 (36%) patients after a mean follow-up of 17 days (range 2-285 days); 14 patients with successful pleurodesis died with a median survival of 61 days (range 13-174 days). Systemic treatment following pleurodesis and good apposition of the pleural surfaces during drainage were good prognostic factors. Despite reasonable-to-good adherence to the guideline, the number of successful pleurodeses was low. Better predictors of a good pleurodesis outcome are needed.
Arnold, Lesley M; Clauw, Daniel J
The current diagnostic and treatment pathway for patients with fibromyalgia (FM) is lengthy, complex, and characterized by multiple physician visits with an average 2-year wait until diagnosis. It is clear that effective identification and appropriate treatment of FM remain a challenge in current clinical practice. Ideally, FM management involves a multidisciplinary approach with the preferable patient pathway originating in primary care but supported by a range of health care providers, including referral to specialist care when necessary. After the publication of individual clinical studies, high-quality reviews, and meta-analyses, recently published FM treatment guidelines have transitioned from an expert consensus to an evidence-based approach. Evidence-based guidelines provide a framework for ensuring early diagnosis and timely adoption of appropriate treatment. However, for successful outcomes, FM treatments must adopt a more holistic approach, which addresses more than just pain. Impact on the associated symptoms of fatigue and cognitive problems, sleep and mood disturbances, and lowered functional status are also important in judging the success of FM therapy. Recently published guidelines recommend the adoption of a symptom-based approach to guide pharmacologic treatment. Emerging treatment options for FM may be best differentiated on the basis of their effect on comorbid symptoms that are often associated with pain (e.g. sleep disturbance, mood, fatigue). The current review discusses the most recently published Canadian guidelines and the implications of the recent European League Against Rheumatism (EULAR) recommendations, with a focus on the challenges of implementing these guidelines in current clinical practice.
Østerås, Nina; van Bodegom-Vos, Leti; Dziedzic, Krysia; Moseng, Tuva; Aas, Eline; Andreassen, Øyvor; Mdala, Ibrahim; Natvig, Bård; Røtterud, Jan Harald; Schjervheim, Unni-Berit; Vlieland, Thea Vliet; Hagen, Kåre Birger
Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8-12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model. A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants' treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER). The results
Fishe, Jennifer N; Crowe, Remle P; Cash, Rebecca E; Nudell, Nikiah G; Martin-Gill, Christian; Richards, Christopher T
As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods. This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported. The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There
Full Text Available Abstract Background Recent guidelines recommend assessment and treatment of the overall risk for cardiovascular disease (CVD through management of multiple risk factors in patients at high absolute risk. The aim of our study was to assess the level of cardiovascular risk in patients with known risk factors for CVD by applying the SCORE risk function and to study the implications of European guidelines on the use of treatment and goal attainment for blood pressure (BP and lipids in the primary care of Cyprus. Methods Retrospective chart review of 1101 randomly selected patients with type 2 diabetes mellitus (DM2, or hypertension or hyperlipidemia in four primary care health centres. The SCORE risk function for high-risk regions was used to calculate 10-year risk of cardiovascular fatal event. Most recent values of BP and lipids were used to assess goal attainment to international standards. Most updated medications lists were used to compare proportions of current with recommended antihypertensive and lipid-lowering drug (LLD users according to European guidelines. Results Implementation of the SCORE risk model labelled overall 39.7% (53.6% of men, 31.3% of women of the study population as high risk individuals (CVD, DM2 or SCORE ≥5%. The SCORE risk chart was not applicable in 563 patients (51.1% due to missing data in the patient records, mostly on smoking habits. The LDL-C goal was achieved in 28.6%, 19.5% and 20.9% of patients with established CVD, DM2 (no CVD and SCORE ≥5%, respectively. BP targets were achieved in 55.4%, 5.6% and 41.9% respectively for the above groups. There was under prescription of antihypertensive drugs, LLD and aspirin for all three high risk groups. Conclusion This study demonstrated suboptimal control and under-treatment of patients with cardiovascular risk factors in the primary care in Cyprus. Improvement of documentation of clinical information in the medical records as well as GPs training for implementation
Olomu, Adesuwa; Hart-Davidson, William; Luo, Zhehui; Kelly-Blake, Karen; Holmes-Rovner, Margaret
Background Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD). Objective: To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician ...
Clausen, N.E.; Bindner, H.; Frandsen, S.; Hansen, J.C.; Hansen, L.H.; Lundsager, P.
The overall objective of this research project is to study the development of methods and guidelines rather than 'universal solutions' for the use of wind energy in isolated communities. So far most studies of isolated systems with wind power have been case-oriented and it has proven difficult to extend results from one project to another, not least due to the strong individuality that has characterised such systems in design and implementation. In the present report a unified and generally applicable approach is attempted in order to support a fair assessment of the technical and economical feasibility of isolated power supply systems with wind energy. General guidelines and checklists on which facts and data are needed to carry out a project feasibility analysis are presented as well as guidelines how to carry out the project feasibility study and the environmental analysis. The report outlines the results of the project as a set of proposed guidelines to be applied when developing a project containing an application of wind in an isolated power system. It is the author's hope that this will facilitate the development of projects and enhance electrification of small rural communities in developing countries. (au)
Machingura, Pasipanodya Ian; Adekola, Olawumi; Mueni, Eunice; Oaiya, Omo; Gustafsson, Lars L; Heller, Richard F
Practice guidelines can be used to support healthcare decision making. We sought to identify the use, and barriers to the implementation, of electronic based guidelines to support decision-making in maternal and child healthcare (MCH) and the rational use of medicines, in developing countries. Graduates who had gained the Master of Public Health degree through the Peoples-uni (postgraduate public health education in developing countries) were sent an online survey questionnaire which had been piloted. Two reminders were sent to non-respondents at intervals of 10 days. Results were explored using descriptive analyses. 44 of the potential 48 graduates from 16 countries responded - most were from Africa. 82% and 89% of respondents were aware of guidelines on MCH and the rational use of medicines respectively. Electronic guidelines were more available in university hospitals than in provincial hospitals or rural care. All respondents thought that guidelines could improve the delivery of quality care, and 42 (95%) and 41 (93%) respectively thought that computers and mobile or smartphones could increase the use of guidelines in service delivery. Lack of access to computers, need to buy phone credit, need for training in the use of either computerized or phone based guidelines and fear of increased workload were potential barriers to use. There is support for the use of electronic guidelines despite limited availability and barriers to use in developing countries. These findings, and other literature, provide a guide as to how the further development of ICT based guidelines may be implemented to improve health care decision making.
This Directive: (1) Implements the policy set forth in references (a), (b) and (c); (2) Assigns responsibilities and prescribes mandatory procedures to open systems implementation with EMDO and Service Ballistic Missile Defense...
Olomu, Adesuwa; Hart-Davidson, William; Luo, Zhehui; Kelly-Blake, Karen; Holmes-Rovner, Margaret
Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD). To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician communication and confidence in decision in low-income population with diabetes and coronary heart disease (CHD) in a Federally Qualified Healthcare Center (FQHC). Ninety-five patients participated in an Office-GAP program. A quasi-experimental design study, over 6 months with 12-month follow-up. Office-GAP program integrates health literacy, communication skills education for patients and physicians, patient/physician decision support tools and SDM into routine care. 1) Implementation rates of planned program elements 2) Patient satisfaction with communication and confidence in decision, and 3) Medication prescription rates. We used the GEE method for hierarchical logistic models, controlling for confounding. Feasibility of the Office-GAP program in the FQHC setting was established. We found significant increase in use of Aspirin/Plavix, statin and beta-blocker during follow-up compared to baseline: Aspirin OR 1.5 (95 % CI: 1.1, 2.2) at 3-months, 1.9 (1.3, 2.9) at 6-months, and 1.8 (1.2, 2.8) at 12-months. Statin OR 1.1 (1.0, 1.3) at 3-months and 1.5 (1.1, 2.2) at 12-months; beta-blocker 1.8 (1.1, 2.9) at 6-months and 12-months. Program elements were consistently used (≥ 98 % clinic attendance at training and tool used). Patient satisfaction with communication and confidence in decision increased. The use of Office-GAP program to teach SDM and use of DAs in real time was demonstrated to be feasible in FQHCs. It has the potential to improve satisfaction with physician communication and
Full Text Available Abstract Background Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed
Harer, M W; Vergales, B; Cady, T; Early, A; Chisholm, C; Swanson, J R
Hypothermia is a common problem in preterm infants immediately following delivery.Local problem:The rate of admission hypothermia in our neonatal intensive care unit (NICU) was above the rate of comparable NICUs in the Vermont Oxford Network. To reduce the rate of preterm admission hypothermia, a quality improvement (QI) project was implemented, utilizing the plan-do-study-act (PDSA) methodology. A guideline for delivery room thermoregulation management in <35-week infants at the University of Virginia was created and put into practice by a multidisciplinary team. Clinical practice changes in the guideline included: increasing operating room temperatures, obtaining a 10-min axillary temperature, using an exothermic mattress for all infants <35 weeks, and using a polyethylene wrap for infants <32 weeks. The baseline rate of hypothermia (<36.5 °CC) was 63%. Three PDSA cycles data were completed on 168 consecutive preterm births. The post-implementation rate of hypothermia (<36.5 °C) was reduced to 30% (P<0.001). The incidence of moderate hypothermia (< 36 °C) was reduced from a baseline of 29% to a rate of 9% (P<0.001). Use of a multidisciplinary guideline to increase preterm NICU admission temperatures resulted in a decrease in hypothermic infants.
Musvoto, Constansia D
Full Text Available The CSIR has developed a guideline for implementing green economy projects in the agriculture sector. The guideline is available for use by agricultural practitioners; and is a tool for translating the principles of a green economy into tangible...
Videbæk Le, Jette; Hansen, Helle P; Riisgaard, Helle
BACKGROUND: Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood....... OBJECTIVE: To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. METHODS: Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form....... Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. RESULTS: Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective...
This code system is designed to calculate site-specific residual radioactive material guidelines, and radiation dose and excess cancer risk to an on-site resident (maximally exposed individual). A guideline is a radionuclide concentration or level of radioactivity that is acceptable if a site is to be used without radiological restrictions. Guidelines are expressed as concentrations of residual radionuclides in soil. Soil is unconsolidated earth material, including rubble and debris that may be present. The guidelines are based on the following principles: (1) the total effective dose equivalent should not exceed 100 mrem/yr for all plausible land uses and 30 mrem/yr for current and likely future land uses and (2) doses should be kept as low as reasonably achievable (ALARA). Nine environmental pathways are considered: direct exposure, inhalation of dust and radon, and ingestion of plant foods, meat, milk, aquatic foods, soil, and water. CCC-0552/04: A - Description of program or function: RESRAD-BUILD Version 2.36 is a pathway analysis model designed to evaluate the potential radiological dose incurred by an individual who works or lives in a building contaminated with radioactive material. The radioactive material in the building structure can be released into the indoor air by mechanisms such as diffusion (radon gas), mechanical removal (decontamination activities), or erosion (removable surface contamination). In the June 1998 update, RESRAD was updated to Version 5.82 and RESRAD-BUILD was updated to version 2.36. The following notes highlight new features: RESRAD5.82 (4/30/98): - Allow plot data to be exported to tab-delimited text file - Corrected Installation problem to Windows 3.1 - Corrected plotting problem for soil guidelines RESRAD-BUILD2.36 (4/9/98): - Corrected problem with simultaneously changing number of wall regions and their parameters - Added OK button to uncertainty window - Made sure first uncertainty variable in added on first try See the
Katz, Manuel; Warshawsky, Sheila S; Rosen, Shirley; Barak, Nurit; Press, Joseph
To develop and implement locally tailored pediatric admission guidelines for use in a pediatric emergency department and evaluate the appropriateness of admissions based on these guidelines. Our Study was based on the development of admission guidelines by senior physicians, using the Delphi Consensus Process, for use in the Pediatric Emergency Department (PED) at Soroka University Medical Center (Soroka). We evaluated the appropriateness of admissions to the pediatric departments of Soroka on 33 randomly selected days in 1999 and 2000 prior to guideline implementation and 30 randomly selected days in 2001, after guideline implementation. A total of 1037 files were evaluated. A rate of 12.4% inappropriate admissions to the pediatric departments was found based on locally tailored admission guidelines. There was no change in the rate of inappropriate admissions after implementation of admission guidelines in PED. Inappropriate admissions were associated with age above 3 years, hospital stay of two days or less and the season. The main reasons for evaluating an admission as inappropriate were that the admission did not comply with the guidelines and that the case could be managed in an ambulatory setting. There were distinctive differences in the characteristics of the Bedouin and Jewish populations admitted to the pediatric departments, although no difference was found in the rate of inappropriate admissions between these populations. Patient management in Soroka PED is tailored to the conditions of this medical center and to the characteristics of the population it serves. The admission guidelines developed reflect these special conditions. Lack of change in the rate of inappropriate admissions following implementation of the guidelines indicates that the guidelines reflect the physicians' approach to patient management that existed in Soroka PED prior to guideline implementation. Hospital admission guidelines have a role in the health management system; however
Jilcott Pitts, S B; Graham, J; Mojica, A; Stewart, L; Walter, M; Schille, C; McGinty, J; Pearsall, M; Whitt, O; Mihas, P; Bradley, A; Simon, C
Healthy foodservice guidelines are being implemented in worksites and healthcare facilities to increase access to healthy foods by employees and public populations. However, little is known about the barriers to and facilitators of implementation. The present study aimed to examine barriers to and facilitators of implementation of healthy foodservice guidelines in federal worksite and hospital cafeterias. Using a mixed-methods approach, including a quantitative survey followed by a qualitative, in-depth interview, we examined: (i) barriers to and facilitators of implementation; (ii) behavioural design strategies used to promote healthier foods and beverages; and (iii) how implementation of healthy foodservice guidelines influenced costs and profitability. We used a purposive sample of five hospital and four federal worksite foodservice operators who recently implemented one of two foodservice guidelines: the United States Department of Health and Human Services/General Services Administration Health and Sustainability Guidelines ('Guidelines') in federal worksites or the Partnership for a Healthier America Hospital Healthier Food Initiative ('Initiative') in hospitals. Descriptive statistics were used to analyse quantitative survey data. Qualitative data were analysed using a deductive approach. Implementation facilitators included leadership support, adequate vendor selections and having dietitians assist with implementation. Implementation barriers included inadequate selections from vendors, customer complaints and additional expertise required for menu labelling. Behavioural design strategies used most frequently included icons denoting healthier options, marketing using social media and placement of healthier options in prime locations. Lessons learned can guide subsequent steps for future healthy foodservice guideline implementation in similar settings. © 2016 The British Dietetic Association Ltd.
Gilbert, T.L.; Yu, C.; Yuan, Y.C.; Zielen, A.J.; Jusko, M.J.; Wallo, A. III; Argonne National Lab., IL; Dames and Moore, West Valley, NY; Argonne National Lab., IL; USDOE Assistant Secretary for Nuclear Energy, Washington, DC
This manual presents information for implementing US Department of Energy (DOE) guidelines for residual radioactive material at sites identified by the Formerly Utilized Sites Remedial Action Program (FUSRAP) and the Surplus Facilities Management Program (SFMP). It describes the analysis and models used to derive site-specific guidelines for allowable residual concentrations of radionuclides in soil and the design and use of the RESRAD computer code for calculating guideline values. It also describes procedures for implementing DOE policy for reducing residual radioactivity to levels that are as low as reasonably achievable. 36 refs., 16 figs, 22 tabs
Fijn, R; Brouwers, JRBJ; Timmer, JW; de Jong-van den Berg, LTW
Several theories behind implementing clinical guidelines have been described within the literature. At first sight, these may seem different. However, there are similarities and eventually they are rather complementary than mutually exclusive. This article integrates several theoretical views on
Mattiolo, Sandra Regina
The environmental management standards are intended to provide to the organizations the elements needed for the implementation of an Environmental Management System (EMS) that can be effectively integrated to another management requirements and assist them to achieve their environmental and economic goals. The Uranium Hexafluoride Production Unit - USEXA, located at the Navy Technological Center in São Paulo, will be the first Brazilian industrial plant responsible for the conversion stage in the nuclear fuel cycle (production of uranium hexafluoride - UF6), allowing added-value to the uranium ore. The EMS proposed to USEXA in this project allows to regulate its interfaces with the environment, since the Standards of CNEN - National Commission of Nuclear Energy and of the IAEA - International Atomic Energy Agency for Nuclear Installations, aim, mostly, to attend the security criteria for the population and the environment, concerning ionizing radiation. This model of EMS fills the gaps in standards of IAEA and CNEN, since it takes into account the environmental impacts from the use of chemicals in the manufacturing process of UF6, and general aspects of sustainability. It can be considered an original contribution within the complex activities that includes the uranium processing in the nuclear fuel cycle. This research proposes, as result, the use of a filter of significance to evaluate the environmental impacts depending on the installation location. It is also presented the Management System Manual for USEXA and models for training in personnel management are suggested, such as coaching and neuro linguistic programing, which can be applied to any Management System. The training can be considered a preventive action as they considerably decreased incidents related to equipment maintenance and thus the occurrence of environmental impacts. (author)
Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming
BACKGROUND: Guidelines are often slowly adapted into clinical practice. However, actively supporting healthcare professionals in evidence-based treatment may speed up guideline implementation. Danish low back pain (LBP) guidelines focus on primary care treatment of LBP, to reduce referrals from p...
Matthew J. Cummings
Full Text Available Abstract Background To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO established a triage tool called “Quick Check” to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition of abnormal vital signs. Despite the availability of these guidelines, recognition of severe illness remains challenged in low-income settings, largely as a result of infrequent vital sign monitoring. Methods We conducted a staggered, pre-post quasi-experimental study at four inpatient health facilities in western Uganda to assess the impact of a multi-modal intervention for improving quality of care following formal training on WHO “Quick Check” guidelines for diagnosis of severe illness in low-income settings. Intervention components were developed using the COM-B (“capability,” “opportunity,” and “motivation” determine “behavior” model and included clinical mentoring by an expert in severe illness care, collaborative improvement meetings with external support supervision, and continuous audits of clinical performance with structured feedback. Results There were 5759 patients hospitalized from August 2014 to May 2015: 1633 were admitted before and 4126 during the intervention period. Designed to occur twice monthly, collaborative improvement meetings occurred every 2–4 weeks at each site. Clinical mentoring sessions, designed to occur monthly, occurred every 4–6 months at each site. Audit and feedback reports were implemented weekly as designed. During the intervention period, there were significant increases in the site-adjusted likelihood of initial assessment of temperature, heart rate, blood pressure, respiratory rate, mental status, and pulse oximetry. Patients admitted during the intervention period were significantly more likely to be diagnosed with sepsis (4.3 vs. 0.4%, risk ratio 10.1, 95% CI 3.0–31
Full Text Available The present supplement summarizes the proceedings of the symposium “Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD”, which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue, the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients’ associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals.
Alanen, Seija I; Johannala-Kemppainen, Riitta; Ijäs, Jarja J
OBJECTIVE: To assess the extent and style of implementation of the Hypertension Guideline (HT Guideline) in Finnish primary health centres, and to identify a scale of contrasting implementation styles in the health centres (with the two ends of the scale being referred to as information...... implementers or disseminators respectively). DESIGN: A cross-sectional study. Development of a questionnaire and criteria for assessing the extent and style of implementation of the HT Guideline. SETTING: Primary healthcare. SUBJECTS: All head physicians and senior nursing officers in Finnish health centres (n...... =290). MAIN OUTCOME MEASURES: The extent of adoption of the HT Guideline in health centres and the characteristics associated with the implementation style. RESULTS: Responses were received from 410 senior medical staff (246 senior nursing officers and 164 head physicians) representing altogether 264...
Kuunders, T.J.M.; Bon-Martens, M.J.H. van; Goor, I.A.M. van de; Paulussen, T.G.W.M.; Oers, H.A.M. van
To develop a targeted implementation strategy for a municipal health policy guideline, implementation targets of two guideline users [Regional Health Services (RHSs)] and guideline developers of leading national health institutes were made explicit. Therefore, characteristics of successful
Kuunders, T.J.M.; Van Bon-martens, M.J.H.; Van De Goor, L.A.M.; Paulussen, T.G.W.M.; Van Oers, J.A.M.
To develop a targeted implementation strategy for a municipal health policy guideline, implementation targets of two guideline users [Regional Health Services (RHSs)] and guideline developers of leading national health institutes were made explicit. Therefore, characteristics of successful
Bosma, Mark; Cassidy, Keri-Leigh; Le Clair, J Kenneth; Helsdingen, Sherri; Devichand, Pratima
Background The Canadian Coalition for Seniors’ Mental Health (CCSMH) developed national best-practice guidelines in seniors’ mental health. Promoting adoption of new guidelines is challenging, as paper dissemination alone has limited impact on practice change. Purpose We hypothesized that the existing knowledge transfer (KT) mechanisms of the Nova Scotia Seniors’ Mental Health Network would prove useful in transferring the CCSMH best-practice guidelines. Methods In this observational KT study, CCSMH best-practice guidelines were delivered through two interactive, case-based teaching modules on Depression & Suicide, and Delirium via a provincial tele-education program and local face-to-face sessions. Usefulness of KT was measured using self-report evaluations of material quality and learning. Evaluation results from the two session topics and from tele-education versus face-to-face sessions were compared. Results Sessions were well attended (N = 347), with a high evaluation return rate (287, 83%). Most participants reported enhanced knowledge in seniors’ mental health and intended to apply knowledge to practice. Ratings did not differ significantly between KT session topics or modes of delivery. Conclusions The KT mechanisms of a provincial seniors’ mental health network facilitated knowledge acquisition and the intention of using national guidelines on seniors’ mental health among Nova Scotian clinicians. Key elements of accelerating KT used in this initiative are discussed. PMID:23251305
Kincaid, Tanna M.; Horner, Erin R.
Discusses diversity in the workplace and offers guidelines for practitioners in designing, developing, and implementing diversity training. Highlights include linking the diversity initiative to the organization's mission, cultural climate assessments, reviewing policies and procedures, needs assessment, learner analysis, establishing objectives,…
Comin, Eva; Catalan-Ramos, Arantxa; Iglesias-Rodal, Manuel; Grau, Maria; Del Val, Jose Luis; Consola, Alicia; Amado, Ester; Pons, Angels; Mata-Cases, Manel; Franzi, Alicia; Ciurana, Ramon; Frigola, Eva; Cos, Xavier; Davins, Josep; Verdu-Rotellar, Jose M
To evaluate the impact of computerized clinical practice guidelines on the management, diagnosis, treatment, control, and follow-up of the main cardiovascular risk factors: hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. Pre-post controlled study. Catalonia, autonomous community located in north-eastern Spain. Individuals aged 35-74 years assigned to general practitioners of the Catalan Health Institute. The intervention group consisted of individuals whose general practitioners had accessed the computerized clinical practice guidelines at least twice a day, while the control group consisted of individuals whose general practitioner had never accessed the computerized clinical practice guidelines platform. The Chi-squared test was used to detect significant differences in the follow-up, control, and treatment variables for all three disorders (hypertension, hypercholesterolaemia, and type 2 diabetes mellitus) between individuals assigned to users and non-users of the computerized clinical practice guidelines, respectively. A total of 189,067 patients were included in this study, with a mean age of 56 years (standard deviation 12), and 55.5% of whom were women. Significant differences were observed in hypertension management, treatment and control; type 2 diabetes mellitus management, treatment and diagnoses, and the management and control of hypercholesterolaemia in both sexes. Computerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
Introduction to Sociological Methods. 2nd ed. New York, McGraw-Hill 14. Denzin , N. K. and Lincoln , Y. S. (2011) The SAGE Handbook of Qualitative...The Art of Science. In: Denzin , N. K. and Lincoln , Y. S. (eds.) Handbook of Qualitative Research. Thousand Oaks, Sage 19. GAO (1990) Case Study...Rinehart & Winston 39. Stake, R. E. (1994) Case Studies. In: Denzin , N. K. and Lincoln , Y. S. (eds.) Handbook of Qualitative Research. Thousand Oaks, Sage
Suman, Arnela; Dikkers, Marije F.; Schaafsma, Frederieke G.; van Tulder, Maurits W.; Anema, Johannes R.
Background: For the optimal use of clinical guidelines in daily practice, mere distribution of guidelines and materials is not enough, and active implementation is needed. This review investigated the effectiveness of multifaceted implementation strategies compared to minimal, single, or no
Clausen, Niels-Erik; Bindner, Henrik W.; Frandsen, Sten Tronæs
The overall objective of this research project is to study the development of methods and guidelines rather than "universal solutions" for the use of wind energy in isolated communities. So far most studies of isolated systems with wind power have beencase-oriented and it has proven difficult...... feasibility of isolated power supply systems with wind energy. General guidelines and checklists on which facts and data are needed to carry out a projectfeasibility analysis are presented as well as guidelines how to carry out the project feasibility study and the environmental analysis. The report outlines...... the results of the project as a set of proposed guidelines to be applied when developing a projectcontaining an application of wind in an isolated power system. It is the author's hope that this will facilitate the development of projects and enhance electrification of small rural communities in developing...
Jansen, Aaltje P D; Muntinga, Maaike E; Bosmans, Judith E; Berghmans, Bary; Dekker, Janny; Hugtenburgh, Jacqueline; Nijpels, Giel; van Houten, Paul; Laurant, Miranda G H; van der Vaart, Huub C H
BACKGROUND: Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a
Deeken, Debra Jean; Wakefield, Douglas; Kite, Cora; Linebaugh, Jeanette; Mitchell, Blair; Parkinson, Deidre; Misra, Madhukar
Ensuring that the level of nurse staffing used to care for patients is appropriate to the setting and service intensity is essential for high-quality and cost-effective care. This article describes the development, validation, and implementation of the clinic technical skills permission list developed specifically to guide nurse staffing decisions in physician clinics of an academic medical center. Results and lessons learned in using this staffing guideline are presented.
Wilding, Dean; Pozzi, Paolo; Soloviev, Oleg; Vdovin, Gleb; Verhaegen, Michel
In life sciences, interest in the microscopic imaging of increasingly complex three dimensional samples, such as cell spheroids, zebrafish embryos, and in vivo applications in small animals, is growing quickly. Due to the increasing complexity of samples, more and more life scientists are considering the implementation of adaptive optics in their experimental setups. While several approaches to adaptive optics in microscopy have been reported, it is often difficult and confusing for the microscopist to choose from the array of techniques and equipment. In this poster presentation we offer a small guide to adaptive optics providing general guidelines for successful adaptive optics implementation.
Full Text Available This report presents guidelines to assist local authorities and traffic engineers with a uniform approach to the implementation of speed humps. It is recommended that these guidelines be read in conjunction with The National Guidelines for Traffic...
Mokkenstorm, Jan; Franx, Gerdien; Gilissen, Renske; Kerkhof, Ad; Smit, Johannes Hendrikus
In The Netherlands, on average 40% of all suicides concern patients treated by mental healthcare institutions (MHIs). Recent evidence indicates that implemented guideline recommendations significantly reduce the odds for patients to die by suicide. Implementation of the multidisciplinary guideline
Joosen, Margot C. W.; van Beurden, Karlijn M.; Terluin, Berend; van Weeghel, Jaap; Brouwers, Evelien P. M.; van der Klink, Jac J. L.
Background: Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived
Amemori, Masamitsu; Korhonen, Tellervo; Kinnunen, Taru; Michie, Susan; Murtomaa, Heikki
Tobacco use adversely affects oral health. Tobacco use prevention and cessation (TUPAC) counselling guidelines recommend that healthcare providers ask about each patient's tobacco use, assess the patient's readiness and willingness to stop, document tobacco use habits, advise the patient to stop, assist and help in quitting, and arrange monitoring of progress at follow-up appointments. Adherence to such guidelines, especially among dental providers, is poor. To improve guideline implementation, it is essential to understand factors influencing it and find effective ways to influence those factors. The aim of the present study protocol is to introduce a theory-based approach to diagnose implementation difficulties of TUPAC counselling guidelines among dental providers. Theories of behaviour change have been used to identify key theoretical domains relevant to the behaviours of healthcare providers involved in implementing clinical guidelines. These theoretical domains will inform the development of a questionnaire aimed at assessing the implementation of the TUPAC counselling guidelines among Finnish municipal dental providers. Specific items will be drawn from the guidelines and the literature on TUPAC studies. After identifying potential implementation difficulties, we will design two interventions using theories of behaviour change to link them with relevant behaviour change techniques aiming to improve guideline adherence. For assessing the implementation of TUPAC guidelines, the electronic dental record audit and self-reported questionnaires will be used. To improve guideline adherence, the theoretical-domains approach could provide a comprehensive basis for assessing implementation difficulties, as well as designing and evaluating interventions. After having identified implementation difficulties, we will design and test two interventions to enhance TUPAC guideline adherence. Using the cluster randomised controlled design, we aim to provide further evidence on
Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.
Ostroff, Jamie S; Li, Yuelin; Shelley, Donna R
Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence. Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence. We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings
Longman, Jo M; Adams, Catherine M; Johnston, Jennifer J; Passey, Megan E
this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up. semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines. antenatal care in the NSW public health system. 27 maternity service managers, obstetricians and midwives. participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour. these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines. Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence. Copyright © 2018 Elsevier Ltd. All rights reserved.
Full Text Available Abstract Background Most guidelines concentrate on investigations, treatment, and monitoring instead of patient history and clinical examination. We developed a guideline that dealt with the different aetiologies of chest pain by emphasizing the patient's history and physical signs. The objective of this study was to evaluate the guideline's acceptance and feasibility in the context of a practice test. Methods The evaluation study was nested in a diagnostic cross-sectional study with 56 General Practitioners (GPs and 862 consecutively recruited patients with chest pain. The evaluation of the guideline was conducted in a mixed method design on a sub-sample of 17 GPs and 282 patients. Physicians' evaluation of the guideline was assessed via standardized questionnaires and case record forms. Additionally, practice nursing staff and selected patients were asked for their evaluation of specific guideline modules. Quantitative data was analyzed descriptively for frequencies, means, and standard deviations. In addition, two focus groups with a total of 10 GPs were held to gain further insights in the guideline implementation process. The data analysis and interpretation followed the standards of the qualitative content analysis. Results The overall evaluation of the GPs participating in the evaluation study regarding the recommendations made in the chest pain guideline was positive. A total of 14 GPs were convinced that there was a need for this kind of guideline and perceived the guideline recommendations as useful. While the long version was partially criticized for a perceived lack of clarity, the short version of the chest pain guideline and the heart score were especially appreciated by the GPs. However, change of clinical behaviour as consequence of the guideline was inconsistent. While on a concrete patient related level, GPs indicated to have behaved as the guideline recommended, the feedback on a more general level was heterogeneous. Several
Garbayo, Luciana; Stahl, James
Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize (avoidable) harm in health care, before guideline implementation.
Conclusions: Computerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear.
Dizon, J M; Grimmer, K; Louw, Q; Machingaidze, S; Parker, H; Pillen, H
The South African allied health (AH) primary healthcare (PHC) workforce is challenged with the complex rehabilitation needs of escalating patient numbers. The application of evidence-based care using clinical practice guidelines (CPGs) is one way to make efficient and effective use of resources. Although CPGs are common for AH in high-income countries, there is limited understanding of how to do this in low- to middle-income countries. This paper describes barriers and enablers for AH CPG uptake in South African PHC. Semi-structured individual interviews were undertaken with 25 South African AH managers, policymakers, clinicians and academics to explore perspectives on CPGs. Interviews were conducted by researcher dyads, one being familiar with South African AH PHC practice and the other with CPG expertise. Rigour and transparency of data collection was ensured. Interview transcripts were analysed by structuring content into codes, categories and themes. Exemplar quotations were extracted to support themes. CPGs were generally perceived to be relevant to assist AH providers to address the challenges of consistently providing evidence-based care in South African PHC settings. CPGs were considered to be tools for managing clinical, social and economic complexities of AH PHC practice, particularly if CPG recommendations were contextusalised. CPG uptake was one way to deal with increasing pressures to make efficient use of scarce financial resources, and to demonstrate professional legitimacy. Themes comprised organisational infrastructures and capacities for CPG uptake, interactions between AH actors and interaction with broader political structures, the nature of AH evidence in CPGs, and effectively implementing CPGs into practice. CPGs contextualised to local circumstances offer South African PHC AH services with an efficient vehicle for putting evidence into practice. There are challenges to doing this, related to local barriers such as geography, AH training
Flemming, Kate; Booth, Andrew; Hannes, Karin; Cargo, Margaret; Noyes, Jane
To outline contemporary and novel developments for the presentation and reporting of syntheses of qualitative, implementation, and process evaluation evidence and provide recommendations for the use of reporting guidelines. An overview of reporting guidelines for qualitative, implementation, and process evaluation evidence syntheses drawing on current international literature and the collective expert knowledge of the Cochrane Qualitative and Implementation Methods Group. Several reporting guidelines exist that can be used or adapted to report syntheses of qualitative, implementation, and process evaluation evidence. Methods to develop individual guidance varied. The use of a relevant reporting guideline can enhance the transparency, consistency, and quality of reporting. Guidelines that exist are generic, method specific, and for particular aspects of the reviewing process, searching. Caution is expressed over the potential for reporting guidelines to produce a mechanistic approach moving the focus away from the content and toward the procedural aspects of the review. The use of a reporting guideline is recommended and a five-step decision flowchart to guide the choice of reporting guideline is provided. Gaps remain in method-specific reporting guidelines such as mixed-study, implementation, and process evaluation evidence syntheses. Copyright © 2017 Elsevier Inc. All rights reserved.
JENNIFER TAN SEE HUI
Full Text Available The International Pharmaceutical Federation (FIP adopted a set of Good Pharmacy Practice (GPP guidelines in 1993 and recommended that the regulatory bodies of individual countries should adapt the guidelines in accordance with their resources. The Malaysian Pharmaceutical Society (MPS introduced its benchmarking guidelines (BMG in 2003 as a means to raise the professional standards of the community pharmacy practice in Malaysia. Therefore, this study aimed to determine the extent to which community pharmacies have adopted the BMG. A cross-sectional study was conducted using mail questionnaires, which were posted to all community pharmacies in Malaysia. A total of 371 questionnaires (29.2% were returned. Only 51.0% of the respondents were aware of the BMG. The extent of compliance with the guidelines was 62.6+21.1% (mean + standard deviation, with a median of 65%. The type and ownership of the community pharmacies were significantly associated with compliance with certain aspects of the guidelines. The main problem in complying with the BMG was financial constraint, and this problem was more likely to occur with independent than with chain pharmacies. However, the respondents generally agreed that most aspects of the BMG could be achieved in less than five years. Since the level of awareness among community pharmacists regarding the BMG is low, the MPS should promote or publicise the BMG further. The BMG should be reviewed before being used as part of the criteria for the accreditation of community pharmacies, as proposed by the MPS to further improve the quality and standards of community pharmacies in Malaysia.
Matthys, Frieda; Soyez, Veerle; van den Brink, Wim; Joostens, Peter; Tremmery, Sabine; Sabbe, Bernard
Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with
Schellevis, F.G.; Eijk, J.T.M. van; Lisdonk, E.H. van de; Velden, J. van der; Weel, C. van
In a prospective longitudinal study over 21 months the performance of general practitioners and the disease status of their patients was measured during the formulation and implementation of guidelines on follow-up care. Data on 15 general practitioners and on 613 patients with hypertension, 95 with
Franx, Gerdien; Gilissen, Renske; Kerkhof, Ad; Smit, Johannes Hendrikus
In The Netherlands, on average 40% of all suicides concern patients treated by mental healthcare institutions (MHIs). Recent evidence indicates that implemented guideline recommendations significantly reduce the odds for patients to die by suicide. Implementation of the multidisciplinary guideline for diagnosis and treatment of suicidal behaviors is a main objective of the Dutch National Suicide Prevention Strategy. To this end, 24 MHIs that collectively reported 73% of patient suicides in 2015 received an educational outreach intervention offered by the national center of expertise. Aim: To investigate changes in levels of implementation of guideline recommendations; and to assess the degree of variation on suicide prevention policies and practices between MHIs. Methods: Implementation study with a prospective cohort design studying change over time on all domains of a Suicide Prevention Monitor, a guideline-based instrument assessing suicide prevention policies and practices within MHIs. Data were collected in six-month intervals between 2015 and 2017. Results: MHIs improved significantly on four out of ten domains: the development of an organizational suicide prevention policy; monitoring and trend-analysis of suicides numbers; evaluations after suicide; and clinician training. No improvement was measured on the domains pertaining to multi-annual training policies; collaborative care with external partners; recording and evaluation of suicide attempts; routine assessment of suicidality in all patients; safety planning and involving next of kin and carers. Furthermore, marked practice variation between MHIs was found which did not decrease over time. Conclusion: This study shows significant improvement in the implementation of four out of ten guideline-based suicide prevention policies in 24 specialist mental healthcare institutions in The Netherlands. The implementation level of suicide prevention policies and practices still appears to vary significantly
Christoffel J. Hendriks
Full Text Available Background: Integrated Financial Management Information Systems (IFMIS can improve public sector management by providing real-time financial information to managers in order to enhance their decision-making capabilities. The South African Public Service is currently busy with the implementation of an IFMIS. However, the implementation of such a project has proved to be a very demanding undertaking and has not been met with resounding success.Objectives: The research was conducted in order to identify the challenges and risks that are involved in the implementation of the IFMIS in South Africa. After identification of the challenges and risks, solutions or guidelines were developed that may make the implementation more successful.Method: The methodology that was used is that of a literature study where theories were explored and used to solve a research problem. Based on the theoretical research, solutions and guidelines were developed to solve challenges and risks experienced.Results: The results indicated that there are a number of challenges involved with the implementation of an IFMIS. A set of best practice guidelines was developed that may make the implementation more successful.Conclusion: The sheer size and complexity of an IFMIS poses significant challenges and a number of risks to the implementation process. There are, however, critical success factors or best practices that can be used for the project to succeed. It is recommended that these best practices be used by the South African Public Service.
Shah, Hemant; Allard, Raymond D; Enberg, Robert; Krishnan, Ganesh; Williams, Patricia; Nadkarni, Prakash M
A large body of work in the clinical guidelines field has identified requirements for guideline systems, but there are formidable challenges in translating such requirements into production-quality systems that can be used in routine patient care. Detailed analysis of requirements from an implementation perspective can be useful in helping define sub-requirements to the point where they are implementable. Further, additional requirements emerge as a result of such analysis. During such an analysis, study of examples of existing, software-engineering efforts in non-biomedical fields can provide useful signposts to the implementer of a clinical guideline system. In addition to requirements described by guideline-system authors, comparative reviews of such systems, and publications discussing information needs for guideline systems and clinical decision support systems in general, we have incorporated additional requirements related to production-system robustness and functionality from publications in the business workflow domain, in addition to drawing on our own experience in the development of the Proteus guideline system (http://proteme.org). The sub-requirements are discussed by conveniently grouping them into the categories used by the review of Isern and Moreno 2008. We cite previous work under each category and then provide sub-requirements under each category, and provide example of similar work in software-engineering efforts that have addressed a similar problem in a non-biomedical context. When analyzing requirements from the implementation viewpoint, knowledge of successes and failures in related software-engineering efforts can guide implementers in the choice of effective design and development strategies.
Kim, Tae Woon; Brijendra Singh.
Reliability Centered Maintenance (RCM) methodology was originally developed by the commercial airlines industry in the early 1960s for identifying applicable and effective preventive maintenance tasks and as currently used in nuclear power industry. Effective maintenance of the systems at a nuclear power plant (NPP) is essential for its safe and reliable operation. Reliability Centered Maintenance at NPP is the program to assure that plant systems remain within an original design criteria and are not adversely affected during the plant life time. The aim of this report is to provide the guidelines to implement the RCM approach on NPP safety systems. Safety systems are usually standby and therefore, we need to periodically detect and repair failures that may have occurred since the previous activation or inspection the equipment. The RCM guidelines are intended to help identify the failure modes and related root causes and then decide the maintenance policies to achieve the high level of safety and reliability. The RCM is intended to improve or maintain high levels of system reliability and plant availability. Since the reliability of plant systems will be improved, the plant safety correspondingly will be increased. Another goal of RCM is to optimize the maintenance and surveillance tasks such that the overall level of resources required to accomplish essential tasks is kept to minimum. RCM also strives to eliminate unnecessary corrective maintenance and to select yet most cost-effective approach to maintenance, testing and inspection for system components. 9 refs. (Author) .new
Saller, T; V Dossow, V; Hofmann-Kiefer, K
Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly. The aim of the current study was to evaluate recent German anesthetists' strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care. In an online survey German hospitals' senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014. The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of
Implementing the NICE osteoarthritis guidelines: a mixed methods study and cluster randomised trial of a model osteoarthritis consultation in primary care--the Management of OsteoArthritis In Consultations (MOSAICS) study protocol.
Dziedzic, Krysia S; Healey, Emma L; Porcheret, Mark; Ong, Bie Nio; Main, Chris J; Jordan, Kelvin P; Lewis, Martyn; Edwards, John J; Jinks, Clare; Morden, Andrew; McHugh, Gretl A; Ryan, Sarah; Finney, Andrew; Jowett, Sue; Oppong, Raymond; Afolabi, Ebenezer; Pushpa-Rajah, Angela; Handy, June; Clarkson, Kris; Mason, Elizabeth; Whitehurst, Tracy; Hughes, Rhian W; Croft, Peter R; Hay, Elaine M
There is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving 'quality markers' of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain. A mixed methods study with a nested cluster randomised controlled trial. This study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive 'whole-system' evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations
Farley, Donna O; Cretin, Shan; Vernez, Georges; Pieklik, Suzanne; Quiter, Elaine; Ashwood, J. S; Tu, Wenli
.... The Quality Management Directorate of the Army Medical Command (MEDCOM) contracted with RAND to work as a partner in the development and testing of guideline implementation methods for ultimate application to an Army-wide guideline program...
Farhoudi, Behnam; SeyedAlinaghi, SeyedAhmad; Tabarsi, Payam; Mohraz, Minoo; Golrokhy, Raheleh; Farnia, Marzieh; Shahbazi, Mohammad; Alasvand, Ramin; Ebrahimi, Bahman; Esfehani, Jafar; Tashakoriyan, Mehrzad
To evaluate the feasibility of the revised "Clinical Guideline for HIV and TB" in the Great Tehran Prison during October 2013 to June 2014. The guideline includes all aspects of HIV/TB diagnosis based on active case finding (ACF), treatment and care services. Before the implementation, a focus group discussion was conducted, and attended by experts on prison health. The objective was to identify defects and limitations of the guideline. After the discussion, the guideline was revised. The Great Tehran Prison contains three separate units; all prisoners are taken first to "reception and identification unit (quarantine)" and then send to two housing units according to their legal status. An HIV ACF strategy was employed in the quarantine, and two units through a voluntary provider-initiated HIV testing. Three staff of the triangular clinic trained the prisoners about common routes of HIV transmission and the symptoms of TB in the units. In the quarantine, all prisoners were examined for all HIV-risk factors, HIV testing and symptoms of TB. In unit one, healthcare staff continued the ACF process, while in unit two, the peers of prisoners were assigned as the healthcare communicators to proceed with the strategy. At this caring process, when the test result was positive, then the process of care, treatment and follow ups was initiated. Moreover, the use of directly observed therapy (DOT) for antiretroviral therapy (ART) and TB was applied to the sick prisoners. There was also a follow-up caring for released prisoner to refer them to care and treatment services outside the prison. The guideline was implemented in the prison successfully. Regarding feasibility of the guideline, the investigators of this study suggest that the guideline should be implemented in other prisons across the country. Copyright© Bentham Science Publishers; For any queries, please email at email@example.com.
Jordan, T. H.
The goal of operational earthquake forecasting (OEF) is to provide the public with authoritative information about how seismic hazards are changing with time. During periods of high seismic activity, short-term earthquake forecasts based on empirical statistical models can attain nominal probability gains in excess of 100 relative to the long-term forecasts used in probabilistic seismic hazard analysis (PSHA). Prospective experiments are underway by the Collaboratory for the Study of Earthquake Predictability (CSEP) to evaluate the reliability and skill of these seismicity-based forecasts in a variety of tectonic environments. How such information should be used for civil protection is by no means clear, because even with hundredfold increases, the probabilities of large earthquakes typically remain small, rarely exceeding a few percent over forecasting intervals of days or weeks. Civil protection agencies have been understandably cautious in implementing formal procedures for OEF in this sort of “low-probability environment.” Nevertheless, the need to move more quickly towards OEF has been underscored by recent experiences, such as the 2009 L’Aquila earthquake sequence and other seismic crises in which an anxious public has been confused by informal, inconsistent earthquake forecasts. Whether scientists like it or not, rising public expectations for real-time information, accelerated by the use of social media, will require civil protection agencies to develop sources of authoritative information about the short-term earthquake probabilities. In this presentation, I will discuss guidelines for the implementation of OEF informed by my experience on the California Earthquake Prediction Evaluation Council, convened by CalEMA, and the International Commission on Earthquake Forecasting, convened by the Italian government following the L’Aquila disaster. (a) Public sources of information on short-term probabilities should be authoritative, scientific, open, and
Full Text Available Abstract Background Guidelines on smoking cessation (SC emphasize healthcare cooperation and community pharmacists' involvement. This study explored the familiarity and implementation of the National SC Guideline in Finnish community pharmacies, factors relating to Guideline familiarity, implementation and provision of SC services. Methods A nationwide mail survey was sent to a systematic, sample of community pharmacy owners and staff pharmacists (total n = 2291. Response rate was 54% (n = 1190. Factors related to the SC Guideline familiarity were assessed by bivariate and multivariate analysis. Results Almost half (47% of the respondents (n = 1190 were familiar with the SC Guideline and familiarity enhanced Guideline implementation. The familiarity was associated with the respondents' perceptions of their personal SC skills and knowledge (OR 3.8; of customers' value of counseling on nicotine replacement therapy (NRT (OR 3.3; and regular use of a pocket card supporting SC counseling (OR 3.0. Pharmacists' workplaces' characteristics, such as size and geographical location were not associated with familiarity. In addition to recommending NRT, the pharmacists familiar with the Guideline used more frequently other Guideline-based SC methods, such as recommended non-pharmacological SC aids, compared to unfamiliar respondents. Conclusions SC Guideline familiarity and implementation is crucial for community pharmacists' involvement in SC actions in addition to selling NRT products. Pharmacists can constitute a potential public health resource in SC easily accessible throughout the country.
van Dijk, Lotte J. E. W.; Nelen, Willianne L. D. M.; D'Hooghe, Thomas M.; Dunselman, Gerard A. J.; Hermens, Rosella P. M. G.; Bergh, Christina; Nygren, Karl G.; Simons, Arnold H. M.; de Sutter, Petra; Marshall, Catherine; Burgers, Jako S.; Kremer, Jan A. M.
Background: Clinical guidelines are intended to improve healthcare. However, even if guidelines are excellent, their implementation is not assured. In subfertility care, the European Society of Human Reproduction and Embryology (ESHRE) guidelines have been inventoried, and their methodological
Kuunders, T.J.M.; Cloin, J.C.M.; van Bon, M.J.H.; Paulussen, T.G.W.M.; van Oers, J.A.M.; van de Goor, L.A.M.
To enhance implementation of a Guideline for integrated local health policy, a draft implementation strategy (DIS) was developed. It was hypothesized that the DIS would be feasible and effective to enhance the use of a Guideline for integrated local health policy. To examine its feasibility and
Everson, Michelle; Zieffler, Andrew; Garfield, Joan
This article introduces the recently adopted Guidelines for the Assessment and Instruction in Statistics Education (GAISE) and provides two examples of introductory statistics courses that have been redesigned to better align with these guidelines.
van der Helm, Jelle; Goossens, Astrid; Bossuyt, Patrick
BACKGROUND: Implementing guidelines can be very difficult. No magic bullet or step-by-step implementation plan is available, neither is any single implementation strategy superior. At the Academic Medical Center (AMC) in Amsterdam, a nursing guideline was developed in 1993 on prevention of patient
Tho, N V; Loan, H T H; Thao, N T P; Dung, N T T; Lan, L T T
The Global Initiative for Asthma (GINA) guidelines have not been implemented effectively in primary care settings in Viet Nam. To estimate the proportion of patients with controlled asthma and the direct health care costs of managing asthma according to GINA guidelines at four out-patient clinics in Ho Chi Minh City (HCMC), Viet Nam. One hundred and six patients with asthma were treated and followed up according to GINA guidelines for 12 months. Clinical and pulmonary function responses and direct health care costs were evaluated every 3 months during the study. The proportion of patients with controlled asthma rose from 1.0% at the start of the study to 36.8% by the end of the study (P Viet Nam, improved asthma control with modest direct health care costs.
Hanks, Thomas C.; Abrahamson, Norm A.; Boore, David M.; Coppersmith, Kevin J.; Knepprath, Nichole E.
In April 1997, after four years of deliberations, the Senior Seismic Hazard Analysis Committee released its report 'Recommendations for Probabilistic Seismic Hazard Analysis: Guidance on Uncertainty and Use of Experts' through the U.S. Nuclear Regulatory Commission as NUREG/CR-6372, hereafter SSHAC (1997). Known informally ever since as the 'SSHAC Guidelines', SSHAC (1997) addresses why and how multiple expert opinions - and the intrinsic uncertainties that attend them - should be used in Probabilistic Seismic Hazard Analyses (PSHA) for critical facilities such as commercial nuclear power plants. Ten years later, in September 2007, the U.S. Geological Survey (USGS) entered into a 13-month agreement with the U.S. Nuclear Regulatory Commission (NRC) titled 'Practical Procedures for Implementation of the SSHAC Guidelines and for Updating PSHAs'. The NRC was interested in understanding and documenting lessons learned from recent PSHAs conducted at the higher SSHAC Levels (3 and 4) and in gaining input from the seismic community for updating PSHAs as new information became available. This study increased in importance in anticipation of new applications for nuclear power facilities at both existing and new sites. The intent of this project was not to replace the SSHAC Guidelines but to supplement them with the experience gained from putting the SSHAC Guidelines to work in practical applications. During the course of this project, we also learned that updating PSHAs for existing nuclear power facilities involves very different issues from the implementation of the SSHAC Guidelines for new facilities. As such, we report our findings and recommendations from this study in two separate documents, this being the first. The SSHAC Guidelines were written without regard to whether the PSHAs to which they would be applied were site-specific or regional in scope. Most of the experience gained to date from high-level SSHAC studies has been for site-specific cases, although three
van der Maaden, Tessa; van der Steen, Jenny T; Koopmans, Raymond T C M; Doncker, Sarah M M M; Anema, Johannes R; Hertogh, Cees M P M; de Vet, Henrica C W
This study aimed to assess the degree of implementation and barriers encountered in the use of a practice guideline for optimal symptom relief for patients with dementia and pneumonia in Dutch nursing homes. A process evaluation included assessment of reach, fidelity, and dose delivered using researcher's observations, and dose received was addressed in a question "use of the practice guideline," which the physicians completed for each patient included in the study. Perceived barriers were assessed with a structured questionnaire (response 69%) and semi-structured interviews (n = 14), which were subject to qualitative content analysis. Of the 55 physicians involved in the intervention phase, 87% attended an implementation meeting; 20 physicians joined the study later (reach). The intervention was implemented as planned, and all intervention components were delivered by the researchers (fidelity and dose delivered). Thirty-six physicians included 109 patients. For 81% of the patients, the treating physician stated to have used the guideline (dose received). The guideline was perceived as providing a good overview of current practice, but some physicians had expected a more directive protocol or algorithm. Further, recommended regular observations of symptoms were rarely performed. Physician's often felt that "this is not different from what we usually do," and with the acute illness, there was not always enough time to (re)familiarize with the contents. The physicians used the practice guideline frequently despite important barriers. Future implementation may involve strategies such as multiple interactive meetings. Further, the greatest potential to alter usual practice should be emphasized, such as using observational instruments. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
Christoffel J. Hendriks
Objectives: The research was conducted in order to identify the challenges and risks that are involved in the implementation of the IFMIS in South Africa. After identification of the challenges and risks, solutions or guidelines were developed that may make the implementation more successful. Method: The methodology that was used is that of a literature study where theories were explored and used to solve a research problem. Based on the theoretical research, solutions and guidelines were developed to solve challenges and risks experienced. Results: The results indicated that there are a number of challenges involved with the implementation of an IFMIS. A set of best practice guidelines was developed that may make the implementation more successful. Conclusion: The sheer size and complexity of an IFMIS poses significant challenges and a number of risks to the implementation process. There are, however, critical success factors or best practices that can be used for the project to succeed. It is recommended that these best practices be used by the South African Public Service.
... of their previous damaging or incompetent performance. The primary evaluation objective was to determine the Military Departments' overall effectiveness in implementing the NPDB program guidelines...
Memoranda from the Chair of EPA's Science Policy Council to the Science Policy Council and the Science Policy Council Steering Committee regarding Implementation of the Cancer Guidelines and Accompanying Supplemental Guidance.
Lingner, H; Burger, B; Kardos, P; Criée, C P; Worth, H; Hummers-Pradier, E
Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations. Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis. Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition. We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues
Full Text Available Efforts in developing guidelines have to be supported by investments on their application. Medical software may have a role in these initiatives. Two computer programs have been developed: one regarding chronic kidney disease and one about chronic pain management. For six months their use by 104 general practitioners was monitored. At study conclusion, a questionnaire of 13 multiple choice questions was emailed to all participating doctors. To evaluate the clinical benefits for the patients, a GP regularly used the CKD program and provided patients’ outcomes and clinical data. The application recorded 108 accesses during 66 work sessions. In the clinical outcomes section of this study, 7 patients out of 21 were diagnosed with CKD. Our study shows a need for programs of the “expert systems” kind: sources devoted to a narrow field of competence, accessed only when needed, in a way that resembles traditional specialist consultation.
Knops, A. M.; Storm-Versloot, M. N.; Mank, A. P. M.; Ubbink, D. T.; Vermeulen, H.; Bossuyt, P. M. M.; Goossens, A.
After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence. A fluid balance guideline (FBG) and body temperature
Wimmelmann, Camila Lawaetz
Guidelines are increasingly used to regulate how local authorities engage in practices. Focusing on the Danish national health promotion guidelines, this article reveals that the local policy workers did not implement the guidelines as proposed. Using a dramaturgical framework, it illustrates how the local policy workers front-staged some…
Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming; Maindal, Helle Terkildsen; Petersen, Karin Dam; Bendtsen, Mette Dahl; Jensen, Martin Bach
) after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]). Using a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines. ClinicalTrials.gov, NCT01699256.
Baum, Katherine T; Powell, Stephanie K; Jacobson, Lisa A; Gragert, Marsha N; Janzen, Laura A; Paltin, Iris; Rey-Casserly, Celiane M; Wilkening, Greta N
Several organizations have published guidelines for the neuropsychological care of survivors of childhood cancer. However, there is limited consensus in how these guidelines are applied. The model of neuropsychology service delivery is further complicated by the variable terminology used to describe recommended services. In an important first step to translate published guidelines into clinical practice, this paper proposes definitions for specific neuropsychological processes and services, with the goal of facilitating consistency across sites to foster future clinical program development and to clarify clinical practice guidelines. © 2017 Wiley Periodicals, Inc.
Barrieren der Leitlinienumsetzung und Fortbildungsbedarf von Hausärzten zur Herzinsuffizienz: eine qualitative Studie [Barriers to guideline implementation and educational needs of general practitioners regarding heart failure: a qualitative study
Full Text Available [english] Objectives: A clinical practice guideline (CPG contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME in HF care.Methods: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically.Results: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps, communicative and organisational skills (e.g. time management and attitude (dissatisfaction with time-money-relation. Patients: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs. Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets and patient education. Conclusion: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education.[german] Zielsetzung: Leitlinien zur Herzinsuffizienz (HI
Full Text Available Abstract Background Tobacco use adversely affects oral health. Tobacco use prevention and cessation (TUPAC counselling guidelines recommend that healthcare providers ask about each patient's tobacco use, assess the patient's readiness and willingness to stop, document tobacco use habits, advise the patient to stop, assist and help in quitting, and arrange monitoring of progress at follow-up appointments. Adherence to such guidelines, especially among dental providers, is poor. To improve guideline implementation, it is essential to understand factors influencing it and find effective ways to influence those factors. The aim of the present study protocol is to introduce a theory-based approach to diagnose implementation difficulties of TUPAC counselling guidelines among dental providers. Methods Theories of behaviour change have been used to identify key theoretical domains relevant to the behaviours of healthcare providers involved in implementing clinical guidelines. These theoretical domains will inform the development of a questionnaire aimed at assessing the implementation of the TUPAC counselling guidelines among Finnish municipal dental providers. Specific items will be drawn from the guidelines and the literature on TUPAC studies. After identifying potential implementation difficulties, we will design two interventions using theories of behaviour change to link them with relevant behaviour change techniques aiming to improve guideline adherence. For assessing the implementation of TUPAC guidelines, the electronic dental record audit and self-reported questionnaires will be used. Discussion To improve guideline adherence, the theoretical-domains approach could provide a comprehensive basis for assessing implementation difficulties, as well as designing and evaluating interventions. After having identified implementation difficulties, we will design and test two interventions to enhance TUPAC guideline adherence. Using the cluster
Watts, Allison W; Mâsse, Louise C; Naylor, Patti-Jean
Background High rates of childhood obesity have generated interest among policy makers to improve the school food environment and increase students’ levels of physical activity. The purpose of this study was to examine school-level changes associated with implementation of the Food and Beverage Sales in Schools (FBSS) and Daily Physical Activity (DPA) guidelines in British Columbia, Canada. Methods Elementary and middle/high school principals completed a survey on the school food and physical...
This article discusses continuing education and the implementation of clinical practice guidelines or best evidence, quality improvement, and patient safety. Continuing education focuses on the perspective of the adult learner and is guided by well-established educational principles. In contrast, guideline implementation and related concepts…
Guidelines are important tools to improve knowledge management, processes and outcomes in health care. Their function is to assist professionals and patients decisions about appropriate and effective practice, especially in those areas of health care where considerable variation or potential for improvement exists. The achievement of a favourable impact necessitates both a systematic and methodically sound approach in the development of guidelines. The German Instrument for Methodological Guideline Appraisal, an adopted and supplemented version of the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, provides 34 quality criteria guideline developers should take into account. However, the impact of guidelines is not only determined by methodological soundness but also by the choice of the guideline topic (need for a guideline), by its dissemination (accessibility) and implementation (acceptance and use). Finally, this impact must be monitored by means of guideline-based quality indicators. (orig.) [de
Kimmons, Joel; Jones, Sonya; McPeak, Holly H; Bowden, Brian
Health and sustainability guidelines for institutional food service are directed at improving dietary intake and increasing the ecological benefits of the food system. The development and implementation of institutional food service guidelines, such as the Health and Human Services (HHS) and General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines), have the potential to improve the health and sustainability of the food system. Institutional guidelines assist staff, managers, and vendors in aligning the food environment at food service venues with healthier and more sustainable choices and practices. Guideline specifics and their effective implementation depend on the size, culture, nature, and management structure of an institution and the individuals affected. They may be applied anywhere food is sold, served, or consumed. Changing institutional food service practice requires comprehensive analysis, engagement, and education of all relevant stakeholders including institutional management, members of the food supply chain, and customers. Current examples of food service guidelines presented here are the HHS and GSA Health and Sustainability Guidelines for Federal Concessions and Vending Operations, which translate evidence-based recommendations on health and sustainability into institutional food service practices and are currently being implemented at the federal level. Developing and implementing guidelines has the potential to improve long-term population health outcomes while simultaneously benefitting the food system. Nutritionists, public health practitioners, and researchers should consider working with institutions to develop, implement, and evaluate food service guidelines for health and sustainability.
Kimmons, Joel; Jones, Sonya; McPeak, Holly H.; Bowden, Brian
Health and sustainability guidelines for institutional food service are directed at improving dietary intake and increasing the ecological benefits of the food system. The development and implementation of institutional food service guidelines, such as the Health and Human Services (HHS) and General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines), have the potential to improve the health and sustainability of the food system. Institutional guidelines assist staff, managers, and vendors in aligning the food environment at food service venues with healthier and more sustainable choices and practices. Guideline specifics and their effective implementation depend on the size, culture, nature, and management structure of an institution and the individuals affected. They may be applied anywhere food is sold, served, or consumed. Changing institutional food service practice requires comprehensive analysis, engagement, and education of all relevant stakeholders including institutional management, members of the food supply chain, and customers. Current examples of food service guidelines presented here are the HHS and GSA Health and Sustainability Guidelines for Federal Concessions and Vending Operations, which translate evidence-based recommendations on health and sustainability into institutional food service practices and are currently being implemented at the federal level. Developing and implementing guidelines has the potential to improve long-term population health outcomes while simultaneously benefitting the food system. Nutritionists, public health practitioners, and researchers should consider working with institutions to develop, implement, and evaluate food service guidelines for health and sustainability. PMID:22585909
Kingsnorth, Shauna; Joachimides, Nick; Krog, Kim; Davies, Barbara; Higuchi, Kathryn Smith
In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Willems, Mia; Schröder, Carin; Post, Marcel; van der Weijden, Trudy; Visser-Meily, Anne
The implementation of clinical practice guidelines in rehabilitation practice is often troublesome and incomplete. An intervention to enhance the implementation of guidelines is the knowledge transfer program built around the activities of a knowledge broker (KB).This study investigates the use of KBs to implement guideline recommendations for intensive therapy and physical activity for patients post-stroke in 22 stroke units in hospitals and rehabilitation centers in The Netherlands. This study includes a quantitative evaluation with a non controlled pre-post intervention design and a mixed methods process evaluation. From each stroke unit, enterprising nurses and therapists will be recruited and trained as KB. The KB will work for one year on the implementation of the guideline recommendations in their team. To evaluate the effectiveness of the KB, a questionnaire will be administered to patients, health professionals and KBs at baseline (T0) and after one year (T1). Furthermore, semi structured interviews with 5 KBs will be performed at T1.The primary outcome of this implementation project will be the support health professionals give patients to exercise and be physically active, as reported by patients and health professionals themselves. The support immediately after the intervention is compared with the support at the start of the intervention.Additionally we will explore the influence of socio-demographic characteristics of health professionals and determinants identified in the Theory of Planned Behavior (intention, attitude, subjective norm and perceived behavioral control) on the change of supportive behavior of health professionals. Finally, KBs will complete a questionnaire on their own psychological and social demographic characteristics and on organizational conditions needed for health-care improvement such as time, workforce, sponsoring and support from management. With this study we will gain insight in when and why knowledge brokers seem to be
Jerardi, Karen E; Elkeeb, Dena; Weiser, Jason; Brinkman, William B
The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011. The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS). The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings. This was a quality improvement implementation study in a large academic medical center. Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider. A multidisciplinary team developed and tested interventions. Impact was assessed with annotated run charts. Statistical comparisons were made with χ(2) analysis and Fisher's exact test. The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department. Rates have been sustained for 12 months and 8 months, respectively. Interventions using the electronic medical record and ordering system were most impactful. Rapid adoption of evidence-based UTI care across multiple settings is achievable. Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting.
Shelley, Donna; Anno, Jaime; Tseng, Tuo-Yen; Calip, Greg; Wedeles, John; Lloyd, Madeleine; Wolff, Mark S
In this study we evaluated the effect of a multicomponent intervention to implement the Public Health Service (PHS) guideline Treating Tobacco Use and Dependence in six randomly selected dental clinics in New York University's College of Dentistry. The main outcome measure-provider adherence to tobacco use treatment guidelines-was assessed by auditing a random selection of patient charts pre (698) and post (641) intervention. The intervention components included a chart reminder and referral system, free nicotine replacement therapy (NRT), and provider training and feedback. The results showed that rates of screening for tobacco use did not change between pre and post test chart audits. However, providers were significantly more likely to offer advice (28.4 percent pre, 49 percent post), assess readiness to quit (17.8 percent pre, 29.9 percent post), and offer assistance (6.5 percent pre and 15.6 percent post) in the post test period. Increases in NRT distribution were associated with booster training sessions but declined in the time periods between those trainings. Research is needed to further define sustainable strategies for implementing tobacco use treatment in dental clinics. The results of this study suggest the feasibility and effectiveness of using a tailored multicomponent approach to implement tobacco use treatment guidelines in dental clinics.
Full Text Available The Canadian Thoracic Society (CTS is leveraging its strengths in guideline production to enable respiratory guideline implementation in Canada. The authors describe the new CTS Framework for Guideline Dissemination and Implementation, with Concurrent Evaluation, which has three spheres of action: guideline production, implementation infrastructure and knowledge translation (KT methodological support. The Canadian Institutes of Health Research ‘Knowledge-to-Action’ process was adopted as the model of choice for conceptualizing KT interventions. Within the framework, new evidence for formatting guideline recommendations to enhance the intrinsic implementability of future guidelines were applied. Clinical assemblies will consider implementability early in the guideline production cycle when selecting clinical questions, and new practice guidelines will include a section dedicated to KT. The framework describes the development of a web-based repository and communication forum to inventory existing KT resources and to facilitate collaboration and communication among implementation stakeholders through an online discussion board. A national forum for presentation and peer-review of proposed KT projects is described. The framework outlines expert methodological support for KT planning, development and evaluation including a practical guide for implementers and a novel ‘Clinical Assembly – KT Action Team’, and in-kind logistical support and assistance in securing peer-reviewed funding.
Due to the large-scale industrial development in Thailand the consumption of energy - primarily based on fossil fuels - has increased enormously, even though the economic growth has slowed down since the economic crisis in 1997. It is, therefore, important to reduce the environmental impact of this energy consumption, which can be achieved by energy conservation, higher efficiency in the production of energy, or by the use of different kinds of renewable energy. This thesis seeks to develop new strategies for the use of waste heat as a part of the industrial process heat, which can be supplied to industries by a district-heating network. By substituting process heat - produced by electricity or by boilers using fossil fuel in individual industries - with process heat, produced by a co-generation plant - using the industries own biomass waste as fuel - process heat can be supplied to industries participating in a small scale district heating network. Thus, an Industrial Materials Network can be created, which is environmentally as well as economically beneficial for both industry and society. On the basis of a case study of the industrial area, Navanakorn Industrial Promotion Zone in Thailand, such initiatives for efficient materials and energy uses have been conducted and proved successful, and industries - as well as local and national governmental agencies, NGOs and branch organizations etc. - have shown interest in supporting the implementation of such scheme. In this thesis, a Guideline for large-scale implementation of Industrial Materials Network in Thailand was developed. By following a series of actions, the Guideline defines the initiatives that must be taken in order to ensure correct implementation. Chronologically, the emphasis of the Guideline is on pointing to relevant stakeholders who can pursue the implementation, and then appropriate areas and types of industries for Industrial Materials Network implementation. Thereafter, guidance for the
Eccles Martin P
Full Text Available Abstract Background Evaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. While implementation depends on clinicians and managers changing a variety of behaviours, psychological theories of behaviour and behaviour change are seldom used to try to understand difficulties in implementation or to develop interventions to overcome them. Objectives This study applied psychological theory to examine explanations for difficulties in implementation. It used a theoretical framework derived from an interdisciplinary consensus exercise to code interviews across 11 theoretical domains. The focus of the study was a National Institute for Health and Clinical Excellence's Schizophrenia guideline recommendation that family intervention should be offered to the families of people with schizophrenia. Methods Participants were recruited from community mental health teams from three United Kingdom National Health Service (NHS Trusts; 20 members (social workers, nurses, team managers, psychologists, and psychiatrists participated. Semi-structured interviews were audio-taped and transcribed. Interview questions were based on the theoretical domains and addressed respondents' knowledge, attitudes and opinions regarding the guideline. Two researchers independently coded the transcript segments from each interview that were related to each theoretical domain. A score of 1 indicated that the transcript segments relating to the domain did not appear to contain description of difficulties in implementation of the family therapy guidelines; similarly a score of 0.5 indicated possible difficulties and a score of 0 indicated definite difficulties. Results Coding respondents' answers to questions related to the three domains 'beliefs about consequences,' 'social/professional role and identity,' and 'motivation' produced the three highest total scores indicating that factors relating
Ochodo, Eleanor; Kredo, Tamara; Young, Taryn; Wiysonge, Charles Shey
Despite the introduction of new tests and guidelines for diagnosis of tuberculosis (TB), worldwide case detection rate of TB is still suboptimal. This could be in part explained by the poor implementation of TB diagnostic guidelines. We aim to identify, appraise and synthesise qualitative evidence exploring the barriers and facilitators to implementing TB diagnostic guidelines. A systematic review of qualitative studies will be conducted. Relevant electronic databases will be searched and studies included based on predefined inclusion criteria. We will also search reference lists, grey literature, conduct forward citation searches and contact relevant content experts. An adaptation of the Critical Appraisal Skills Programme tool will be used to assess the methodological quality of included studies. Two authors will review the search output, extract data and assess methodological quality independently, resolving any disagreements by consensus. We will use the thematic framework analysis approach based on the Supporting the Use of Research Evidence thematic framework to analyse and synthesise our data. We will apply the Confidence in the Evidence from Reviews of Qualitative research approach to transparently assess our confidence in the findings of the systematic review. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42016039790 TRIAL REGISTRATION NUMBER: PROSPERO 2016: CRD42016039790. Available from http://www.crd.york.ac.uk/PROSPERO/. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Deuster, S; Roten, I; Muehlebach, S
Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice. A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained. The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0.05). Antibiotic treatment guidelines for the
Porter, Cornelia P.; Pender, Nola J.; Hayman, Laura L.; Armstrong, Myrna L.; Riesch, Susan K.; Lewis, Mary Ann
Discusses recommendations for preparing advanced practice nurses (APNs) to implement guidelines of a health curriculum: (1) ensuring age-appropriate teaching; (2) emphasizing the complex relationships of race/ethnicity, socioeconomic status, and gender; (3) reinforcing the self-care and resilience of adolescents; and (4) examining transitions…
While methods for the production of guidelines (evidence analysis, assessment, adaptation) have been continually refined throughout the past years, there is a lack of instruments for the production of easily understandable synopses. Definition of a methodological approach to encompass synopses by Spidernet diagrams. Tables of synopses can be generated with distinct information to bring down the main results in one Spidernet diagram. This is possible for both the entire synopsis and parts of it. Guideline comparisons require detailed analyses on the one hand and easily understandable presentations of their results on the other. Guideline synopses can be substantially supported by graphic presentation of the results of synopsis. Graphic synopsis is also helpful in other cases; it may be used, for example, to summarise HTA reports, systematic reviews or guidelines. Copyright © 2011. Published by Elsevier GmbH.
Bensch, Gunther; Peters, Jörg; Schmidt, Christoph M.
There is a consensus in the international community that rural electrification and, in particular, the productive use of electricity contributes to poverty alleviation. At the same time, efforts to evaluate the impacts of development projects have increased substantially. This paper provides a hands-on guide for designing evaluation studies regarding the impacts of productive electricity usage. Complementary to the existing literature on evaluation methods, this guide familiarizes project managers with the concrete steps that have to be undertaken to plan and implement an evaluation. The guide comprises three modules based on enterprise surveys and on anecdotal case studies. For each module, the implementation is described on a step-by-step basis including conceptual issues as well as logistics and methodological questions. - Highlights: ► Hands-on evaluation guideline for development project managers. ► Step-by-step procedure on how to implement evaluation. ► Impacts of productive electricity use.
Background: Clinical guidelines when implemented correctly have shown to improve disease outcomes. This study describes utilization of Kenya National guidelines in managing ante partum haemorrhage (APH) in 3rd trimester. Objective: To describe adherence to clinical guideline in management of antepartum ...
A draft of the structured record was developed at a single-pilot CHC in the Western Cape. Focus group discussions established the core requirements for a structured record. Process, result and structural indicators in line with the national Guidelines were considered for inclusion in the draft record. This draft record was then ...
Avey, Marc T; Fenwick, Nicole; Griffin, Gilly
In 1959, Russell and Burch published The Principles of Humane Experimental Technique, which included concrete advice on factors that they considered would govern progress in the implementation of these principles (enunciated as the 3Rs [Replacement, Reduction, and Refinement in animal-based studies]). One challenge to the implementation of the 3Rs was identified as information retrieval. Here, we further explore this challenge—the need for ‘research on research’—and the role that systematic reviews and reporting guidelines can play in implementation of the 3Rs. First, we examine the 2-fold nature of the challenge of information retrieval: 1) the identification of relevant publications spread throughout a large population of nonrelevant publications and 2) the incomplete reporting of relevant details within those publications. Second, we evaluate how systematic reviews and reporting guidelines can be used generally to address this challenge. Third, we assess the explicit reporting of the 3Rs in a cohort of preclinical animal systematic reviews. Our results show that Reduction methods are the most commonly reported by authors of systematic reviews but that, in general, reporting on how findings relate to the 3Rs is limited at best. Although systematic reviews are excellent tools for resolving the challenge of information retrieval, their utility for making progress in implementation of the 3Rs may be limited unless authors improve their reporting of these principles. PMID:25836961
Joubert, M; Baillot-Rudoni, S; Catargi, B; Charpentier, G; Esvant, A; Franc, S; Guerci, B; Guilhem, I; Melki, V; Merlen, E; Penfornis, A; Renard, E; Riveline, J P; Schaepelynck, P; Sola-Gazagnes, A; Hanaire, H
The benefits of retrospective continuous glucose monitoring (retroCGM) recording have been widely explored in clinical studies, and many diabetes physicians routinely use this examination. However, the method of interpretation of CGM recordings has never been precisely described. An expert French panel of physicians met for two days to discuss several aspects of retroCGM use and to produce a position statement. The guidelines cover the indications for retroCGM, the general organization and practical implementation of CGM recordings, a description of the different devices available and guidelines for the interpretation of retroCGM recordings. This consensus document should help clinicians in the proper use of retroCGM. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Francke, A.L.; Smit, M.C.; Veer, A.J.E. de; Mistiaen, P.
BACKGROUND: Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect
Joosen, Margot C W; van Beurden, Karlijn M; Terluin, Berend; van Weeghel, Jaap; Brouwers, Evelien P M; van der Klink, Jac J L
Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs' barriers were evaluated. OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs' experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training. The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs' knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.
van der Wees, Philip J; Zagers, Cor A M; de Die, Sara E; Hendriks, Erik J M; Nijhuis-van der Sanden, Maria W G; de Bie, Rob A
Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation planning. This study aimed at developing a questionnaire to identify perceived barriers for implementing the Dutch COPD guideline for physical therapists and its recommended measurement instruments. An overall questionnaire, based on two existing questionnaires, was constructed to identify barriers and facilitators for implementing the COPD guideline. The construct of the questionnaire was assessed in a cross-sectional study among 246 chest physical therapists. Factor analysis was conducted to explore underlying dimensions. Psychometric properties were analyzed using Cronbach's alpha. Barriers and facilitators were assessed using descriptive statistics. Some 139 physical therapists (57%) responded. Factor analysis revealed 4-factor and 5-factor solutions with an explained variance of 36% and 39% respectively. Cronbach's alpha of the overall questionnaire was 0.90, and varied from 0.66 to 0.92 for the different factors. Underlying domains of the 5-factor solution were characterized as: attitude towards using measurement instruments, knowledge and skills of the physical therapist, applicability of the COPD guideline, required investment of time & money, and patient characteristics. Physical therapists showed a positive attitude toward using the COPD guideline. Main barriers for implementation were required time investment and financial constraints. The construct of the questionnaire revealed relevant underlying domains for the identification of barriers and facilitators for implementing the COPD guideline. The questionnaire allowed for tailoring to the target group and may be used across health care professionals as basis for in-depth analysis of barriers to specific recommendations in
Törmä, Johanna; Winblad, Ulrika; Saletti, Anja; Cederholm, Tommy
Suboptimal nutritional practices in elderly care settings may be resolved by an efficient introduction of nutritional guidelines. To compare two different implementation strategies, external facilitation (EF) and educational outreach visits (EOVs), when introducing nutritional guidelines in nursing homes (NHs), and study the impact on staff performance. A quasi-experimental study with baseline and follow-up measurements. The primary outcome was staff performance as a function of mealtime ambience and food service routines. The EF strategy was a 1-year, multifaceted intervention that included support, guidance, practice audit and feedback in two NH units. The EOV strategy comprised one-three-hour lecture about nutritional guidelines in two other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Mealtime ambience was evaluated by 47 observations using a structured mealtime instrument. Food service routines were evaluated by 109 food records performed by the staff. Mealtime ambience was more strongly improved in the EF group than in the EOV group after the implementation. Factors improved were laying a table (p = 0.03), offering a choice of beverage (p = 0.02), the serving of the meal (p = 0.02), interactions between staff and residents (p = 0.02) and less noise from the kitchen (p = 0.01). Food service routines remained unchanged in both groups. An EF strategy that included guidance, audit and feedback improved mealtime ambience when nutritional guidelines were introduced in a nursing home setting, whereas food service routines were unchanged by the EF strategy. © 2017 Nordic College of Caring Science.
result in the adaptation and use of the guideline (Hayward, 1996). Desirable Attributes of CPGs It is also important to understand what attributes of...effectiveness in relation to costs that the CPG achieves. To determine what is being done well and what could be done better, it is necessary to research...Acetaminophen: The generic name for a common nonprescription medication useful in the treatment of mild pain or fever. This is called paracetamol in
..., 2010, the National Oceanic and Atmospheric Administration published its annual notice entitled... Atmospheric Administration Availability of Grant Funds and Proposed Implementation Guidelines; Withdrawal of Solicitation for the Marine Aquaculture Initiative AGENCY: National Oceanic and Atmospheric Administration...
Fahad A Al-Hussein
Conclusions: A process of audits in the context of statistical process control is necessary for any improvement in the implementation of guidelines in primary care. Statistical process control charts are an effective means of visual feedback to the care providers.
Consistent with The Office of Management and Budgets (OMB) Guidelines (for Ensuring and Maximizing the Quality, Objectivity, Utility, and Integrity of Information Disseminated by Federal Agencies) implementing Section 515 of the Treasury and Gener...
-saving £−93.20 (£406.51 vs. £499.71 per patient after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]. Conclusions Using a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines. Trial registration ClinicalTrials.gov, NCT01699256
Hadar, Eran; Mansur, Nariman; Ambar, Irit; Hod, Moshe
Preterm delivery is a significant cause of neonatal morbidity and mortality. Pregnant women, with symptoms and signs consistent with preterm labor, can be treated with various tocolytic drugs. Atosiban is one of many drugs indicated to arrest imminent preterm labor. Various studies show that the efficacy of atosiban is similar to other tocolytic drugs. The main advantage of atosiban is a relativeLy low incidence of adverse maternal reactions. Its considerable shortcoming is the financial cost, compared to other available drugs. In view of its cost, we have decided to implement a strict protocol to direct the use of atosiban, with the intent to reduce costs, without hampering quality of care. The protocol was implemented from July 2009, and it outlines the medical and procedural terms to use atosiban. We compared similar time periods before and after implementation of the protocol. The outcomes compared included: treatment success, rates of preterm deliveries and financial costs. Within the timeframe that the protocol was implemented, we have been able to demonstrate a 40% reduction in atosiban related costs, compared to a parallel period, when the clinical guidelines were not implemented. This translates into savings of about NIS 40,000 (New Israeli Shekel) (approximately $10,000). This was achieved without an increase in the rate of preterm deliveries. Implementing and enforcing a simple protocol of supervision on the use of atosiban enables a considerable reduction of financial costs related to atosiban, without hampering medical care.
Ollenschläger, Günter; Lelgemann, Monika; Kopp, Ina
In Germany, physicians enrolled in disease management programs are legally obliged to follow evidence-based clinical practice guidelines. That is why a Program for National Disease Management Guidelines (German DM-CPG Program) was established in 2002 aiming at implementation of best-practice evidence-based recommendations for nationwide as well as regional disease management programs. Against this background the article reviews programs, methods and tools for implementing DM-CPGs via clinical pathways as well as regional guidelines for outpatient care. Special reference is given to the institutionalized program of adapting DM-CPGs for regional use by primary-care physicians in the State of Hesse.
Braspenning, J C C; Mettes, T G P H; van der Sanden, W J M; Wensing, M J P
Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.
Lind, S; Wallin, L; Brytting, T; Fürst, C J; Sandberg, J
In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care. Copyright © 2017 Elsevier B.V. All rights reserved.
Background High rates of childhood obesity have generated interest among policy makers to improve the school food environment and increase students’ levels of physical activity. The purpose of this study was to examine school-level changes associated with implementation of the Food and Beverage Sales in Schools (FBSS) and Daily Physical Activity (DPA) guidelines in British Columbia, Canada. Methods Elementary and middle/high school principals completed a survey on the school food and physical activity environment in 2007–08 (N = 513) and 2011–12 (N = 490). Hierarchical mixed effects regression was used to examine changes in: 1) availability of food and beverages; 2) minutes per day of Physical Education (PE); 3) delivery method of PE; and 4) school community support. Models controlled for school enrollment and community type, education and income. Results After policy implementation was expected, more elementary schools provided access to fruits and vegetables and less to 100% fruit juice. Fewer middle/high schools provided access to sugar-sweetened beverages, French fries, baked goods, salty snacks and chocolate/candy. Schools were more likely to meet 150 min/week of PE for grade 6 students, and offer more minutes of PE per week for grade 8 and 10 students including changes to PE delivery method. School community support for nutrition and physical activity policies increased over time. Conclusion Positive changes to the school food environment occurred after schools were expected to implement the FBSS and DPA guidelines. Reported changes to the school environment are encouraging and provide support for guidelines and policies that focus on increasing healthy eating and physical activity in schools. PMID:24731514
Full Text Available The objectives of developing an implementation guideline to international standard school for schools under secondary educational service area office 25 were ; 1 to study present and problem an implementation guideline to international standard school for schools under secondary educational service area office 25 and 2 to develop an implementation guideline to international standard school for schools under secondary educational service area office 25. There were 68 samples ; administrators, deputy administrators, head of quality management systems, and academic teachers by purposive sampling. The tools used to collect the data were the five level scale questionnaire and structured interviews. Data were analyzed using mean, standard deviation, and descriptive analysis. The researcher set the research by 2 phase. The first phase educated present and problem an implementation guideline to international standard school for schools under secondary educational service area office 25. The research was assessed feasibility of developing an implementation guideline to international standard school for schools under secondary educational service area office 25 by 5 experts. The research results were: 1. The present and problem an implementation guideline to international standard school for schools under secondary educational service area office 25 found that the overall present were at the high level and each one was at the high level. The overall problem were at the low and each one was at the moderate 2 aspects ; The leadership and the focus on personnel. Then it was at the low level. 2. Developing an implementation guideline to international standard school for schools under secondary educational service area office 25 found that 1 the leadership had set with the vision, values, performance of the school’s senior leadership, including good governance of the school, implementation of the ethics law, and responsibility for the community, 2 strategic
Bekkering, Geertruida E; van Tulder, Maurits W; Hendriks, Erik J M; Koopmanschap, Marc a; Knol, Dirk L; Bouter, Lex M; Oostendorp, Rob a B
BACKGROUND AND PURPOSE: An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain. The effect of this strategy on patients' physical functioning, coping strategy, and beliefs regarding their low back pain was studied.
Downs Shauna M
Full Text Available Abstract Background Although the mandate of recreational facilities is to enhance well-being, many offer foods inconsistent with recommendations for healthy eating. Little is known regarding recreational facility food environments and how they might be improved, as few studies exist. The Alberta Nutrition Guidelines for Children and Youth (ANGCY are intended to ensure access to healthy food choices in schools, childcare and recreational facilities. This study investigated awareness, adoption and implementation of the ANGCY among recreational facilities in Alberta, Canada, one year following their release. Methods A cross-sectional telephone survey was conducted from June - December, 2009 (n = 151 with managers of publicly funded recreational facilities that served food. The questionnaire included 10 closed and 7 open ended questions to assess the organizational priority for healthy eating, awareness, adoption and implementation of the ANGCY. Chi-squared tests examined quantitative variables, while qualitative data were analysed using directed content analysis. Greenhalgh's model of diffusion of complex innovations within health service organizations constituted the theoretical framework for the study. Results One half of respondents had heard of the ANGCY, however their knowledge of them was limited. Although 51% of facilities had made changes to improve the nutritional quality of foods offered in the past year, only a small fraction (11% of these changes were motivated by the ANGCY. At the time of the survey, 14% of facilities had adopted the ANGCY and 6% had implemented them. Barriers to adoption and implementation were primarily related to perceived negative attributes of the ANGCY, the inner (organizational context, and negative feedback received during the implementation process. Managers strongly perceived that implementing nutrition guidelines would limit their profit-making ability. Conclusions If fully adopted and implemented, the ANGCY
Thorsen, Thorkil; Mäkelä, M.
implementering af klinisk vejledninger Forskningsdesign og statistiske spørgsmål i implementeringsforskningØkonomisk evaluering Kvalitative metoderMetoder til at identificere barrierer for brug af kliniske vejledninger Planlægning og monitorering af implementeringsforløbMåling af holdninger til kliniske...
Hategeka, A.; Karenzi, P.C.
This chapter reports on the energy scene in Rwanda, and discusses the evolution of the energy development concept in the framework of national development policy, biomass and other energy sources, biomass supply and demand, and commercialised wood and biomass consumption. Prospects to stabilise the biomass cycle are examined, and the implementation of biomass energy policy in Rwanda is considered. (UK)
Spallek, Heiko; Song, Mei; Polk, Deborah E; Bekhuis, Tanja; Frantsve-Hawley, Julie; Aravamudhan, Krishna
Objective The purpose of this study is to identify barriers that early-adopting dentists perceive as common and challenging when implementing recommendations from evidence-based (EB) clinical guidelines. Method This is a cross-sectional study. Dentists who attended the 2008 Evidence-based Dentistry Champion Conference were eligible for inclusion. Forty-three dentists (34%) responded to a 22-item questionnaire administered online. Two investigators independently coded and categorized responses to open-ended items. Descriptive statistics were computed to assess the frequency of barriers and perceived challenges. Results The most common barriers to implementation are difficulty in changing current practice model, resistance and criticism from colleagues, and lack of trust in evidence or research. Barriers perceived as serious problems have to do with lack of up-to-date evidence, lack of clear answers to clinical questions, and contradictory information in the scientific literature. Conclusions Knowledge of barriers will help improve translation of biomedical research for dentists. Information in guidelines needs to be current, clear, and simplified for use at chairside; dentists’ fears need to be addressed. PMID:21093800
Horriat, S; Hamilton, P D; Sott, A H
To review the financial aspects of implementing the latest NICE guideline for neck of femur fracture (CG124), which recommends offering Total Hip Replacement (THR) as an alternative to hemiarthroplasty (HA) for patients, who are independently mobile before injury, not cognitively impaired and well enough to tolerate the operation. Between April 2011 and April 2013 data collected from our Hip Fracture database (NHFD) showed that by following the latest NICE guideline (CG124), out of 840 patients, 176 patients (21%) should be considered for THR rather than HA. Individual procedure costs were calculated by considering cost of implants and consumables (extracted from providers' published catalogues) added to the cost of running operating theatre for each operation. We then used the national tariff for each procedure using relevant HRG codes to calculate the total cost and the income to the Trust. Our data indicated that by implementing the latest NICE guideline (CG124), 37.1% of patients with intra-capsular fracture neck of femur (IC-NOF fracture) would be eligible for THR rather than HA. Although performing cemented THR was the more expensive procedure, our calculation shows that despite increased cost of performing the operation, Trusts can increase their net income by £300-600 (depending on their market force factor) per patient using correct HRG coding and National Tariff. Utilising 2012-13 National Tariff, performing a cemented THR instead of a HA for patients with IC-NOF fracture, as recommended by the latest NICE guideline (CG124) can increase the Trust's revenue per patient in a predictable way. This practice not only results in potentially better patient outcomes but also can increase financial reward and potential for reinvestment in all hip fracture units in the UK. Copyright © 2014 Elsevier Ltd. All rights reserved.
Lundemo, Marie Therese; Woodley, John
in order to apply and implement them in industrial processes, both from a biological and process perspective. Indeed, a combined approach of host selection and cell engineering, integrated with process engineering, is suggested as the most effective route to implementation.......Biocatalytic reactions performed by cytochrome P450 monooxygenases are interesting in pharmaceutical research since they are involved in human drug metabolism. Furthermore, they are potentially interesting as biocatalysts for synthetic chemistry because of the exquisite selectivity of the chemistry...... they undertake. For example, selective hydroxylation can be undertaken on a highly functionalized molecule without the need for functional group protection. Recent progress in the discovery of novel P450s as well as protein engineering of these enzymes strongly encourages further development of their application...
E. Davis, R. Bickford
Industry and EPRI experience at several plants has shown on-line monitoring to be very effective in identifying out-of-calibration instrument channels or indications of equipment-degradation problems. The EPRI implementation project for on-line monitoring has demonstrated the feasibility of on-line monitoring at several participating nuclear plants. The results have been very encouraging, and substantial progress is anticipated in the coming years
Presentation. The growth of multinational enterprises and integration of world markets across national borders has increased the importance of this issue: How should corporate tax systems at the national level be applied to the profits of companies engaging in the vast number of cross border transactions? The challenges and implications of the issue are tremendous both to the national governments and to the enterprises. The OECD countries have responded to these challenges by declaring that each enterprise within a multinational group of companies shall be treated as a separate entity. In order to apply the separate entity approach to intra group transactions, individual group members must be taxed on the basis that they act at arm's length with each other. The arm's length principle is more easily understood in theory than applied in practice. In some countries, therefore, the authorities have explored other methods than the traditional ones, as described in the 1979 Transfer Pricing Report of the OECD. A confirmed consensus between the governments was reached in the form of the revised 1995 guidelines. The Norwegian Ministry of Finance has given its full support to the efforts of defending the separate entity approach and the arm's length principle in the OECD committees.
The aim of this thesis is to draw an outline of how to implement revenue management in the restaurant industry. The practice well-known in the hotel and airline industry is proven to be suitable for the food and beverage businesses. First of all, the key strategic levers, price and duration, are presented and defined. Based on the basic principle that the demand for a product varies according to its price, the application of modern pricing and dynamic pricing is introduced in this thesis....
Holmgren, Stina; Silfver, Kristina Gren; Lind, Cecilia; Nordström, Lennart
To describe an extensive process to implement guidelines for oxytocin use during labor and to report its effects on compliance to clinical practice guidelines after 1 year. A multifaceted strategy was developed to involve all obstetric staff and identify possible local barriers to change in advance. The process lasted for more than 1 year. To describe the implementation of oxytocin use according to the new guidelines, and to compare management in clinical practice with guideline recommendations from audits performed before and after the project. Identification of possible barriers to change, academic detailing, audits with feedback, and local opinion leaders were important factors for a successful process. Documentation of the indication for oxytocin use increased from 54% before, to 86% after the completion of the project (Pcheck list to monitor oxytocin use. However, audits with feedback need to continue for medical safety, and have been planned to take place every 6 months. Copyright Â© 2011 Elsevier B.V. All rights reserved.
Kyle, Ursula G; Lucas, Laura A; Mackey, Guisela; Silva, Jaime C; Lusk, Jennifer; Orellana, Renan; Shekerdemian, Lara S; Coss-Bu, Jorge A
Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality. The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU). This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively. Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation). Implementation of NS Guidelines. Changes in actual energy and protein intake in the post- compared with the pre-Implementation period. Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score. After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (Pprotein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively. The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a
Evans-Agnew, Robin A; Klein, Nicole; Lecce, Sally
Managing asthma in the schools is complex and requires careful planning. This article highlights key steps in implementing guideline-based care for children with asthma in Washington State schools: assessing students, establishing acuity, communicating with parents, and training staff. Advance planning can improve outcomes for students, parents, and school staff in managing this complex and prevalent disease. NASN recently developed asthma management guidelines. Developing state-specific guidelines provides an opportunity to speak specifically to state laws and nurse practice acts while also reinforcing the importance of specialized practice to school nurses, school administrators and teachers, parents, and students. © 2015 The Author(s).
Doak, J.; Howell, J.A.
This work was initially performed for the International Atomic Energy Agency (IAEA) to help with the Open Source Task of the 93 + 2 Initiative; however, the information should be of interest to anyone working with open sources. The authors cover all aspects of an open source information system (OSIS) including, for example, identifying relevant sources, understanding copyright issues, and making information available to analysts. They foresee this document as a reference point that implementors of a system could augment for their particular needs. The primary organization of this document focuses on specific aspects, or components, of an OSIS; they describe each component and often make specific recommendations for its implementation. This document also contains a section discussing the process of collecting open source data and a section containing miscellaneous information. The appendix contains a listing of various providers, producers, and databases that the authors have come across in their research.
Wees, P.J. van der; Zagers, C.A.; Die, S.E. de; Hendriks, E.J.; Nijhuis-Van der Sanden, M.W.G.; Bie, R.A. de
BACKGROUND: Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation
Zahanova, Stacy; Tsouka, Alexandra; Palmert, Mark R; Mahmud, Farid H
Clinical practice guidelines (CPG) provide evidence-based recommendations for patient care but may not be optimally applied in clinical settings. As a pilot study, we evaluated the impact of a computerized, point-of-care decision support system (CDSS) on guideline knowledge and adherence in our diabetes clinic. iSCREEN, a CDSS, integrated with a province-wide electronic health record, was designed based on the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Evaluation data were gathered by retrospective chart review and clinician questionnaire prior to and after implementation of iSCREEN. Records of patients with type 1 diabetes, 14 to 18 years of age, were assessed for appropriate screening for complications and comorbidities. To assess guideline adherence, 50 charts were reviewed at 2 time periods (25 before and 25 after launch of iSCREEN). Results revealed improved frequency of appropriate screening for diabetic nephropathy (p=0.03) and retinopathy (p=0.04), accompanied by a decrease in under- and overscreening for these outcomes. To assess guideline knowledge, 58 surveys were collected (31 prior to and 27 after the launch of iSCREEN) from care providers in the field of pediatric diabetes. There was a trend toward improved guideline knowledge in all team members (p=0.06). Implementation of a de novo CDSS was associated with improved rates of appropriate screening for diabetes-related complications. A trend toward improvement in health professionals' knowledge of the guidelines was also observed. Evaluation of this point-of-care computerized decision support tool suggests that it may facilitate diabetes care by optimizing complication screening and CPG knowledge, with the potential for broader implementation. Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.
Zwerver, Feico; Bonefaas-Groenewoud, Karin; Schellart, Antonius J. M.; Anema, Johannes R.; van der Beek, Allard J.
Background: We developed an implementation strategy for the insurance medicine guidelines for depression, which we implemented via a post-graduate course for insurance physicians (IPs). In this study we evaluate the physicians' experiences of the implementation strategy by measuring the following aspects: recruitment and reach, dose delivered and…
McGrath, John C; Lilley, Elliot
The ARRIVE guidelines have been implemented in BJP for 4 years with the aim of increasing transparency in reporting experiments involving animals. BJP has assessed our success in implementing them and concluded that we could do better. This editorial discusses the issues and explains how we are changing our requirements for authors to report their findings in experiments involving animals. This is one of a series of editorials discussing updates to the BJP Instructions to Authors Video To view the video on the ARRIVE guidelines, visit: https://www.youtube.com/watch?v=DYXoUAnhoPM PMID:25964986
Sitati, Emmily M.; Ndirangu, Mwangi; Kennedy, Bota; Rapongo, George S.
In 2006, the Kenyan Ministry of Education (MoE) developed an early childhood development education (ECDE) service standard guidelines to guide the ECDE stakeholders in provision of early childhood education (ECE) programmes. The study sought to investigate the implementation of the ECDE service standard guidelines on provision of physical…
Francke, Anneke L; Smit, Marieke C; de Veer, Anke J E; Mistiaen, Patriek
Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field. A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews. Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals - e.g., awareness of the existence of the guideline and familiarity with its content - likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines
de Veer Anke JE
Full Text Available Abstract Background Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field. Methods A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1 screening on the basis of references and abstracts and (2 screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews. Results Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals – e.g., awareness of the existence of the guideline and familiarity with its content – likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for
Blume, L.H.K.; van Weert, N.J.H.W.; Busari, J.O.; Stoopendaal, A.M.V.; Delnoij, D.
Rationale, aims and objectives This study provides insight into how Dutch hospitals ensure that guidelines are used in practice and identifies what key messages other hospitals can learn from existing practices. We examine current practices in handling compliance and, therefore, focus on hospitals
Kemp, Joanne L; Newton, Joshua D; White, Peta E; Finch, Caroline F
While guidelines outlining the appropriate management of sport-related concussion have been developed and adapted for use within community sport, it remains unknown how they are experienced by those responsible for implementing them. Longitudinal study. 111 coaches and sports trainers from community-level Australian Football and Rugby League teams completed pre- and post-season surveys assessing their attitudes towards using concussion guidelines. Participants also provided post-season feedback regarding their experiences in using the guidelines. 71% of participants reported using the guidelines in the preceding season. Post-season attitude was related to pre-season attitude (p=0.002), football code (p=0.015), and team role (p=0.045). An interaction between team role and guideline use (p=0.012) was also found, with coaches who had used the guidelines, and sports trainers who had not, reporting more positive post-season attitudes towards using the concussion guidelines. Implementation challenges included disputing of decisions about return-to-play by players, parents, and coaches, and a perceived lack of time. Recommendations for improved guideline materials included using larger fonts and providing for witnessing of advice given to players. This is the first study to examine the implementation of concussion guidelines in community sport. Training of coaches/sports trainers needs enhancement. In addition, new education should be developed for parents/players about the importance of the return-to-play advice given to them by those who follow these guidelines. Information provided by those who attempted to use the guidelines will assist the refinement of implementation and dissemination processes around concussion guidelines across sports. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Grace, James B.; Schoolmaster, Donald R.; Guntenspergen, Glenn R.; Little, Amanda M.; Mitchell, Brian R.; Miller, Kathryn M.; Schweiger, E. William
Structural equation modeling (SEM) is increasingly being chosen by researchers as a framework for gaining scientific insights from the quantitative analyses of data. New ideas and methods emerging from the study of causality, influences from the field of graphical modeling, and advances in statistics are expanding the rigor, capability, and even purpose of SEM. Guidelines for implementing the expanded capabilities of SEM are currently lacking. In this paper we describe new developments in SEM that we believe constitute a third-generation of the methodology. Most characteristic of this new approach is the generalization of the structural equation model as a causal graph. In this generalization, analyses are based on graph theoretic principles rather than analyses of matrices. Also, new devices such as metamodels and causal diagrams, as well as an increased emphasis on queries and probabilistic reasoning, are now included. Estimation under a graph theory framework permits the use of Bayesian or likelihood methods. The guidelines presented start from a declaration of the goals of the analysis. We then discuss how theory frames the modeling process, requirements for causal interpretation, model specification choices, selection of estimation method, model evaluation options, and use of queries, both to summarize retrospective results and for prospective analyses. The illustrative example presented involves monitoring data from wetlands on Mount Desert Island, home of Acadia National Park. Our presentation walks through the decision process involved in developing and evaluating models, as well as drawing inferences from the resulting prediction equations. In addition to evaluating hypotheses about the connections between human activities and biotic responses, we illustrate how the structural equation (SE) model can be queried to understand how interventions might take advantage of an environmental threshold to limit Typha invasions. The guidelines presented provide for
Andrade, Vera Lúcia Fonseca; Fernandes, Filipa Alexandra Veludo
to describe strategies used by health professionals on the implementation of the Centers for Disease Control and Prevention guidelines for the prevention of urinary infection related to catheterism. systematic review on literature based on data from CINAHL(r), Nursing & Allied Health Collection, Cochrane Plus Collection, MedicLatina, MEDLINE(r), Academic Search Complete, ACS - American Chemical Society, Health Reference Center Academic, Nursing Reference Center, ScienceDirect Journals and Wiley Online Library. A sample of 13 articles was selected. studies have highlighted the decrease of urinary tract infection related to catheterism through reminder systems to decrease of people submitted to urinary catheterism, audits about nursing professionals practice and bundles expansion. the present review systemizes the knowledge of used strategies by health professionals on introduction to international recommendations, describing a rate decrease of such infection in clinical practice.
Full Text Available Abstract Background Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings. Methods A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD, foot complications in diabetes, smoking cessation and venous leg ulcers. Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review. Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation. Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation and follow-up telephone interviews (n = 152 pre, 121 post. Interviews were conducted with 83/95 (87% CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation. Results While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%, diabetes foot care (83% and venous leg ulcers (60%. Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack
Atthobari, Jarir; Bos, Jasper M.; Boersma, C.; Brouwers, J.R.B.J.; de Jong-van den Berg, Lolkje T.W.; Postma, Maarten
Objective: This study examines the adherence of Dutch pharmacoeconomic studies to the national guidelines of conducting a pharmacoeconomic evaluation. Methods: Dutch guidelines for pharmacoeconomic research were issued in 1999. All Dutch pharmacoeconomic studies that were published in English during
Breimaier, Helga E; Heckemann, Birgit; Halfens, Ruud J G; Lohrmann, Christa
Implementing clinical practice guidelines (CPGs) in healthcare settings is a complex intervention involving both independent and interdependent components. Although the Consolidated Framework for Implementation Research (CFIR) has never been evaluated in a practical context, it appeared to be a suitable theoretical framework to guide an implementation process. The aim of this study was to evaluate the comprehensiveness, applicability and usefulness of the CFIR in the implementation of a fall-prevention CPG in nursing practice to improve patient care in an Austrian university teaching hospital setting. The evaluation of the CFIR was based on (1) team-meeting minutes, (2) the main investigator's research diary, containing a record of a before-and-after, mixed-methods study design embedded in a participatory action research (PAR) approach for guideline implementation, and (3) an analysis of qualitative and quantitative data collected from graduate and assistant nurses in two Austrian university teaching hospital departments. The CFIR was used to organise data per and across time point(s) and assess their influence on the implementation process, resulting in implementation and service outcomes. Overall, the CFIR could be demonstrated to be a comprehensive framework for the implementation of a guideline into a hospital-based nursing practice. However, the CFIR did not account for some crucial factors during the planning phase of an implementation process, such as consideration of stakeholder aims and wishes/needs when implementing an innovation, pre-established measures related to the intended innovation and pre-established strategies for implementing an innovation. For the CFIR constructs reflecting & evaluating and engaging, a more specific definition is recommended. The framework and its supplements could easily be used by researchers, and their scope was appropriate for the complexity of a prospective CPG-implementation project. The CFIR facilitated qualitative data
Peleška, Jan; Zvára Jr., Karel; Tomečková, Marie; Zvárová, Jana
20 Suppl. 4, - (2002), s. 86 ISSN 0263-6352. [Scientific Meeting of the International Society of Hypertension /19./, Europeean Meeting on Hypertension /12./. 23.06.2002-27.06.2002, Prague] R&D Projects: GA MŠk LN00B107 Grant - others:MGT(XE) EC 4.FP Keywords : guidelines for hypertension * implementation * computer assisted implementation Subject RIV: BA - General Mathematics
Calvin Cuartero, M.; Vega Riber, R. de la; Martin Calvarro, J. M.
The most important aspects of the Basic Guideline focus on their area of planning, groups of potential radiological emergencies in the type of activity associated with the levels of response planning and responsible organizations, structure and functions for each level, radiological criteria, implementation and maintenance of the effectiveness of the level of response plans abroad.
Dawson, Beverly Araujo; Fenster, Judy
Although web-based courses in schools of social work have proliferated over the past decade, the literature contains few guidelines on steps that schools can take to develop such courses. Using Knowles's framework, which delineates tasks and themes involved in implementing e-learning in social work education, this article describes the cultivation…
Zwerver, Feico; Schellart, Antonius J M; Anema, Johannes R; van der Beek, Allard J
To improve guideline adherence by insurance physicians (IPs), an implementation strategy was developed and investigated in a randomized controlled trial. This implementation strategy involved a multifaceted training programme for a group of IPs in applying the guidelines for depression. In this study we report the impact of the implementation strategy on the physicians' attitude, intention, self-efficacy, and knowledge and skills as behavioural determinants of guideline adherence. Any links between these self-reported behavioural determinants and levels of guideline adherence were also determined. Just before and 3 months after the implementation of the multifaceted training, a questionnaire designed to measure behavioural determinants on the basis of the ASE (attitude, social norm, self-efficacy) model was completed by the intervention (n = 21) and the control group (n = 19). Items of the questionnaire were grouped to form scales of ASE determinants. Internal consistency of the scales was calculated using Cronbach's alphas. Differences between groups concerning changes in ASE determinants, and the association of these changes with improvements in guideline adherence, were analyzed using analysis of covariance. The internal consistency of the scales of ASE determinants proved to be sufficiently reliable, with Cronbach's alphas of at least 0.70. At follow-up after 3 months, the IPs given the implementation strategy showed significant improvement over the IPs in the control group for all ASE determinants investigated. Changes in knowledge and skills were only weakly associated with improvements in guideline adherence. The implementation strategy developed for insurance physicians can increase their attitude, intention, self-efficacy, and knowledge and skills when applying the guidelines for depression. These changes in behavioural determinants might indicate positive changes in IPs' behaviour towards the use of the guidelines for depression. However, only changes in
Full Text Available Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs, yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a fourmonth leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the
Tistad, Malin; Palmcrantz, Susanne; Wallin, Lars; Ehrenberg, Anna; Olsson, Christina B.; Tomson, Göran; Holmqvist, Lotta Widén; Gifford, Wendy; Eldh, Ann Catrine
Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future
Elaboration of the evaluation guidelines for activities implemented jointly (AIJ) was researched to prevent the earth from warming. AIJ is the means to globally promote countermeasures against global warming cost-effectively by optimally combining every country`s technology, know-how and fund. AIJ was established in the 1st Conference of the Parties (COPI) of the United Nations Framework Convention on Climate Change in March, 1995. The pilot phase of AIJ is first carried out by voluntary workers jointly with developing countries under the agreement of the parties. The current situation of activities is reported in COPI as materials for evaluation of AIJ. To promote AIJ, elaboration of the evaluation guidelines for AIJ Japan program is also necessary for Japan. This research arranged the contents of the evaluation guidelines and the method of classifying projects for AIJ Japan program, and carried out some case studies of promising projects to reduce greenhouse gas emission for future proposal. 3 figs., 31 tabs.
Johnson, J A; Caudle, K E; Gong, L; Whirl-Carrillo, M; Stein, C M; Scott, S A; Lee, M T; Gage, B F; Kimmel, S E; Perera, M A; Anderson, J L; Pirmohamed, M; Klein, T E; Limdi, N A; Cavallari, L H; Wadelius, M
This document is an update to the 2011 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2C9 and VKORC1 genotypes and warfarin dosing. Evidence from the published literature is presented for CYP2C9, VKORC1, CYP4F2, and rs12777823 genotype-guided warfarin dosing to achieve a target international normalized ratio of 2-3 when clinical genotype results are available. In addition, this updated guideline incorporates recommendations for adult and pediatric patients that are specific to continental ancestry. © 2017 American Society for Clinical Pharmacology and Therapeutics.
Full Text Available Aim. This study aimed to investigate how public health nurses identify, intervene in, and implement the guidelines on child maltreatment in Finland and Japan and to compare the data between the two countries. Method. This study employed a cross-sectional design. Public health nurses’ knowledge and skills with respect to child maltreatment prevention were assessed using a questionnaire consisting of three categories: identification, intervention, and implementation of guidelines. Public health nurses working in the area of maternal and child health care in Finland (n=193 and Japan (n=440 were the participants. Results. A significantly higher percentage of Japanese public health nurses identified child maltreatment compared to Finnish public health nurses, while Finnish nurses intervened in child maltreatment better than their Japanese counterparts. In both countries, public health nurses who had read and used the guidelines dealt with child maltreatment better than those who did not. Conclusion. The results suggest that effective training on child maltreatment and the use of guidelines are important to increase public health nurses’ knowledge and skills for identifying and intervening in child maltreatment.
Olstad, Dana Lee; Raine, Kim D; McCargar, Linda J
Little is known about how public entities can partner with industry to achieve public health goals. We investigated industry's perspective of factors that influenced their adoption and implementation of voluntary, government-issued nutrition guidelines (Alberta Nutrition Guidelines for Children and Youth, ANGCY) in recreational facilities. In-depth semi-structured interviews were conducted. Data were analysed using directed content analysis. Food services in recreational facilities. Seven managers from industry participated; five from companies that had adopted and implemented the ANGCY (adopters) in recreational facilities and two from companies that had not (non-adopters). Industry views nutrition guidelines through the lens of profitability. Non-adopters were unwilling to implement the ANGCY for fear of sacrificing short-term profitability, whereas adopters adhered to them in an attempt to position themselves for long-term profitability. Adopters faced barriers including few resources, no training, complex guidelines, low availability of and demand for ANGCY-compliant products, competitive pressures and substantial declines in revenue. Managers believed widespread voluntary adoption of the ANGCY was unlikely without government incentives and/or a mandate, as the environmental context for voluntary action was poor. All managers supported government-mandated implementation of the ANGCY to level the playing field upon which companies compete. Public-private partnerships in recreational facilities can embrace public health goals in the short term, provided industry perceives potential for long-term financial gain. Widespread uptake of voluntary nutrition guidelines in this setting is unlikely, however, as market mechanisms do not encourage industry to sell and promote healthier options. Government legislation may therefore be warranted.
Porgo, Teegwendé V; Ferri, Mauricio; Norris, Susan L
In 2007, WHO established the Guidelines Review Committee (GRC) to ensure that WHO guidelines adhere to the highest international standards. The GRC reviews guideline proposals and final guidelines. The objectives of this study were to examine the rates of and reasons for conditional approval and non-approval of documents submitted for the first time to the GRC, and calculate the time intervals and numbers of submissions to achieve approval for documents conditionally approved or not approved at first submission. All initial submissions to the GRC between 2014 and 2017 were examined. Data were extracted from the GRC's records of written comments and discussions. Of a total of 85 proposals and 88 final guidelines, 32 (37.6%) proposals and 37 (42.0%) final guidelines were conditionally approved, and 15 (17.6%) proposals and 28 (31.8%) final guidelines were not. For both conditionally approved and not approved proposals, the most frequent reasons were suboptimal composition or inadequate description of the guideline contributor groups (in all proposals), followed by inadequate formulation of key questions (in 90.6% of conditionally approved proposals and all not approved proposals). For both conditionally approved and not approved final guidelines, the most frequent reasons were problems with recommendations (in all final guidelines), followed by inappropriate methods for evidence retrieval or an inadequate description thereof (in all conditionally approved final guidelines and 75.0% of not approved final guidelines). The median time to achieve approval was 2 months for proposals and 1-2 months for final guidelines. The median number of submissions was 2 for proposals and 2-2.5 for final guidelines. The GRC implements a rigorous quality assurance process and identifies problems with a significant percentage of initial submissions. WHO needs to continuously evaluate its guideline development processes to inform effective quality improvement measures and optimise the
Sánchez Díaz, Natalia; Duarte Osorio, Andrés; Gómez Restrepo, Carlos; Bohórquez Peñaranda, Adriana Patricia
To present overall strategies and activities for the implementation process of the recommendations contained in the clinical practice guideline for the management of adults with schizophrenia (GPC_E) published by the Colombian Ministry of Health and Welfare (MSPS). Prioritize the proposed recommendations, identify barriers and solving strategies to implement the GPC_E, and develop a monitoring and evaluation system for the key recommendations. The Guideline Developer Group (GDG) included professionals with primary dedication to implementation issues that accompanied the entire process. During the GDG meetings implementation topics were identified and discussed, and later complemented by literature reviews concerning the experience of mental health guidelines implementation at national and international level. Additionally, feedback from the discussions raised during the socialization meetings, and joint meetings with the MSPS and the Institute of Technology Assessment in Health (IETS) were included. The prioritization of recommendations was made in conjunction with the GDG, following the proposed steps in the methodological guide for the development of Clinical Practice Guidelines with Economic Evaluation in the General System of Social Security in Colombian Health (GMEGPC) using the tools 13 and 14. the conclusions and final adjustments were discussed with the GPC_E leaders. The implementation chapter includes a description of the potential barriers, solution strategies, facilitators and monitoring indicators. The identified barriers were categorized in the following 3 groups: Cultural context, health system and proposed interventions. The issues related to solving strategies and facilitating education programs include community mental health, mental health training for health workers in primary care, decentralization and integration of mental health services at the primary care level, use of technologies information and communication and telemedicine. To monitor
GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING): a pilot cluster randomised controlled trial of a guideline implementation intervention for the management of maternal obesity by midwives.
Heslehurst, Nicola; Rankin, Judith; McParlin, Catherine; Sniehotta, Falko F; Howel, Denise; Rice, Stephen; McColl, Elaine
Weight management in pregnancy guidelines exist, although dissemination alone is an ineffective means of implementation. Midwives identify the need for support to overcome complex barriers to practice. An evaluation of an intervention to support midwives' guideline implementation would require a large-scale cluster randomised controlled trial. A pilot study is necessary to explore the feasibility of delivery and evaluation prior to a definitive trial. The GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING) trial aims to test whether it is feasible and acceptable to deliver a behaviour change intervention to support midwives' implementation of weight management guidelines. GLOWING is a multi-centre parallel group pilot cluster randomised controlled trial comparing the delivery of a behaviour change intervention for midwives versus usual practice. Four NHS Trusts (clusters) will be randomised to intervention and control arms, stratified by size of maternity services. The intervention uses social cognitive theory and consists of face-to-face midwifery training plus information resources for routine practice. The main outcomes are whether the intervention and trial procedures are feasible and acceptable to participants and the feasibility of recruitment and data collection for a definitive trial. Target recruitment involves all eligible midwives in the intervention arm recruited to receive the intervention, 30 midwives and pregnant women per arm for baseline and outcome questionnaire data collection and 20 midwives and women to provide qualitative data. All quantitative and qualitative analyses will be descriptive with the purpose of informing the development of the definitive trial. This pilot study has been developed to support community midwives' implementation of guidelines. Community midwives have been selected as they usually carry out the booking appointment which includes measuring and discussing maternal body mass index. A
A cost effectiveness study establishing the impact and accuracy of implementing the NICE guidelines lowering plasma NTproBNP threshold in patients with clinically suspected heart failure at our institution.
Webb, Jessica; Draper, Jane; Rua, Tiago; Yiu, Yee; Piper, Susan; Teall, Thomas; Fovargue, Lauren; Bolca, Elena; Jackson, Tom; Claridge, Simon; Sieniewicz, Ben; Porter, Bradley; McDiarmid, Adam; Rajani, Ronak; Kapetanakis, Stamatis; Rinaldi, Christopher A; Razavi, Reza; McDonagh, Theresa A; Carr-White, Gerald
The 2014 National Institute of Clinical Excellence (NICE) guidelines on the management of acute heart failure recommended using a plasma NT-proBNP threshold of 300pg/ml to assist in ruling out the diagnosis of heart failure (HF), updating previous guidelines recommending using a threshold of 400pg/ml. NICE based their recommendations on 6 studies performed in other countries. This study sought to determine the diagnostic and economic implications of using these thresholds in a large unselected UK population. Patient and clinical demographics were recorded for all consecutive suspected HF patients over 12months, as well as clinical outcomes including time to HF hospitalisation and time to death (follow up 15.8months). Of 1995 unselected patients admitted with clinically suspected HF, 1683 (84%) had a NTproBNP over the current NICE recommended threshold, of which 35% received a final diagnosis of HF. Lowering the threshold from 400 to 300pg/ml would have involved screening an additional 61 patients and only would have identified one new patient with HF (sensitivity 0.985, NPV 0.976, area under the curve (AUC) at 300pg/ml 0.67; sensitivity 0.983, NPV 0.977, AUC 0.65 at 400pg/ml). The economic implications of lowering the threshold would have involved additional costs of £42,842.04 (£702.33 per patient screened, or £ 42,824.04 per new HF patient). Applying the recent updated NICE guidelines to an unselected real world population increases the AUC but would have a significant economic impact and only identified one new patient with heart failure. Copyright © 2017 Elsevier B.V. All rights reserved.
Chiari, Paolo; Fontana, Mirella; Bianchi, Tommaso; Bonzagni, Cristina; Galetti, Caterina
Although guidelines for the management of pressure sores are widely available, their implementation is not always easy and sometimes does not produce the desired changes. To describe the results of a clinical audit aiming at assessing the appropriate use of medications for pressure sores, after the implementation of guidelines. The audit group, with an expert in assessment, a nurse expert in pressure sores, a microbiologist, a dermatologist and a chemist analysed the clinical and nursing records of all the patients with a pressure sore, discharged during the first trimester of 2005 and 2006, after the implementation of the guidelines, from wards with higher prevalence of pressure sores: geriatric, medical, intensive care, rehabilitation and post acute wards. Each documented treatment was classified as appropriate, not appropriate or "grey area", treatments inappropriate according to guidelines but not according to expert or current knowledge (e.g. poliurethane medications for heel pressure sores). After each stage, the results were returned and discussed with the involved wards. One hundred 74 patients were surveyed in 2005 and 199 in 2006, with a total of respectively 287 and 326 sores. The percentage of inappropriate treatments was 20% in 2005 and 12.8% in 2006 (OR 1.79 I.C. 95% 1.10- 2.91), while an increase of treatments considered grey area (from 7% to 13.5%) was observed. The medium number of medications used was 17.3 per lesion, in 2005 and 16.4 in 2006 with a cost respectively of 83.6 and 67.35 per lesion, but the two populations were not strictly comparable. Clinical audit is a strategy that involving doctors and nurses, may promote positive changes. The rate of inappropriate treatments (higher in areas with high turnover of nurses) can be improved with educational interventions. The identification of treatments of the grey area highlights the need of periodically revising guidelines to update their contents according to new knowledge and technologies.
Yang, Samantha Peiling; Ying, Lee Suat; Saw, Stephanie; Tuttle, R Michael; Venkataraman, Kavita; Su-Ynn, Chia
Numerous published guidelines have described the optimal management of thyroid cancer. However, these rely on the clinical availability of diagnostic and therapeutic modalities. We hypothesized that the availability of medical resources and economic circumstances vary in Asia-Pacific countries, making it difficult to implement guideline recommendations into clinical practice. We surveyed participants at the 2009 and 2013 Congresses of the Association of Southeast Asian Nations Federation of Endocrine Societies by distributing questionnaires to attendees at registration. Responses were obtained from 268 respondents in 2009 and 163 respondents in 2013. Similar to the high prevalence of low-risk thyroid cancer observed in the Surveillance, Epidemiology, and End Results database, across the Asia-Pacific countries surveyed in 2009 and 2013, 50 to 100% of the respondents from the Philippines, Malaysia, Singapore, China, Taiwan, Thailand, Hong Kong, Korea, and Sri Lanka reported that more than 50% of the patients had low-risk thyroid cancer on follow-up. Importantly, there was much variation with regards to the perceived availability of investigation and treatment modalities. We found a wide variation in clinicians' perception of availability of diagnostic and therapeutic modalities in the face of a rise in thyroid cancer incidence and thyroid cancer management guidelines that emphasized their importance. The lack of availability of management tools and treatments will prove to be a major barrier to the implementation of thyroid cancer management guidelines in Southeast Asia, and likely in other parts of the world as well.
Remmen, Kari Beate; Frøyland, Merethe
Teachers find the implementation of fieldwork challenging. Therefore, this study investigates two teachers' implementation of theoretical guidelines for student-centered fieldwork activities, following their participation in a professional development course focusing on earth science fieldwork pedagogy. Video observation and instructional…
Licskai, Christopher; Sands, Todd; Ong, Michael; Paolatto, Lisa; Nicoletti, Ivan
Quality problem International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets. Initial assessment Regional pilot data demonstrated a knowledge-to-practice gap. Choice of solutions We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework. Implementation Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient. Evaluation Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ± 24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (P< 0.001) post-intervention; 71% reported urgent/emergent healthcare visits at baseline (2.94 visits/year) vs. 45% (1.45 visits/year) (P< 0.001); 39% reported absenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ± 7) months. Lessons learned A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1.
Licskai, Christopher; Sands, Todd; Ong, Michael; Paolatto, Lisa; Nicoletti, Ivan
Quality problem International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets. Initial assessment Regional pilot data demonstrated a knowledge-to-practice gap. Choice of solutions We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework. Implementation Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient. Evaluation Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ±24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (Pabsenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ±7) months. Lessons learned A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1 PMID:22893665
Wang, Jianhui [Argonne National Lab. (ANL), Argonne, IL (United States); Chen, Chen [Argonne National Lab. (ANL), Argonne, IL (United States); Lu, Xiaonan [Argonne National Lab. (ANL), Argonne, IL (United States)
This guideline focuses on the integration of DMS with DERMS and microgrids connected to the distribution grid by defining generic and fundamental design and implementation principles and strategies. It starts by addressing the current status, objectives, and core functionalities of each system, and then discusses the new challenges and the common principles of DMS design and implementation for integration with DERMS and microgrids to realize enhanced grid operation reliability and quality power delivery to consumers while also achieving the maximum energy economics from the DER and microgrid connections.
Full Text Available Abstract Background Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM to improve inpatient smoking cessation. Specific objectives The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention. Design Pre-post study design in four VA hospitals Participants Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day. Intervention The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy, computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units. Outcomes The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the
Full Text Available Abstract Objective Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs. The aim of this study was to validate a methodology for Priority Determination of Topics (PDT of CPGs. Methods and results Firstly, we developed an instrument for PDT with 41 criteria that were grouped under 10 domains, based on a comprehensive systematic search. Secondly, we performed a survey of stakeholders involved in CPGs development, and end users of guidelines, using the instrument. Thirdly, a pilot testing of the PDT procedure was performed in order to choose 10 guideline topics among 34 proposed projects; using a multi-criteria analysis approach, we validated a mechanism that followed five stages: determination of the composition of groups, item/domain scoring, weights determination, quality of the information used to support judgments, and finally, topic selection. Participants first scored the importance of each domain, after which four different weighting procedures were calculated (including the survey results. The process of weighting was determined by correlating the data between them. We also reported the quality of evidence used for PDT. Finally, we provided a qualitative analysis of the process. The main domains used to support judgement, having higher quality scores and weightings, were feasibility, disease burden, implementation and information needs. Other important domains such as user preferences, adverse events, potential for health promotion, social effects, and economic impact had lower relevance for clinicians. Criteria for prioritization were mainly judged through professional experience, while good quality information was only used in 15% of cases. Conclusion The main advantages of the proposed methodology are supported by the use of a systematic approach to identify, score and weight guideline topics selection, limiting or exposing the influence of personal biases
Suman, Arnela; Schaafsma, Frederieke G; van de Ven, Peter M; Slottje, Pauline; Buchbinder, Rachelle; van Tulder, Maurits W; Anema, Johannes R
To improve patient care, and to reduce unnecessary referrals for diagnostic imaging and medical specialist care for low back pain, an evidence-based guideline for low back pain was developed in the Netherlands in 2010. The current study evaluated the effect of a multifaceted implementation strategy on guideline adherence among Dutch general practitioners. The implementation strategy included a multidisciplinary training, provision of educational material and an interactive website for healthcare professionals, supported by a multimedia eHealth intervention for patients with low back pain. Adherence was measured using performance indicators based on 3 months data extracted from the contacts with patients with low back pain recorded in the electronic medical records of participating general practitioners. Performance indicators were compared between two groups: a usual care group and an implementation group. Performance indicators were referrals to consultations with medical specialists, to diagnostic imaging, and to psychosocial and/or occupational physician consultations, and inquiries about psychosocial and occupational risk factors. The electronic medical records of 5130 patient contacts for LBP were analysed; 2453 patient contacts in the usual care group and 2677 patient contacts in the implementation group. Overall, rates of referral and of recorded inquiries regarding psychosocial and occupational risk factors remained low in both groups over time. The only statistically significant difference found was a reduction in the number of referrals to neurologists in the implementation group (from 100 (7%) to 50 (4%)) compared to the usual care group (from 48 (4%) to 50 (4%), (p strategy did not result in improved guideline adherence among general practitioners, and it is not recommended for widespread use. However, baseline referral rates in participating practices were already low, possibly leaving only little room for improvement. Inquiries for psychosocial and
Full Text Available Abstract Background PROforma is one of several languages that allow clinical guidelines to be expressed in a computer-interpretable manner. How these languages should be compared, and what requirements they should meet, are questions that are being actively addressed by a community of interested researchers. Methods We have developed a system to allow hypertensive patients to be monitored and assessed without visiting their GPs (except in the most urgent cases. Blood pressure measurements are performed at the patients' pharmacies and a web-based system, created using PROforma, makes recommendations for continued monitoring, and/or changes in medication. The recommendations and measurements are transmitted electronically to a practitioner with authority to issue and change prescriptions. We evaluated the use of PROforma during the knowledge acquisition, analysis, design and implementation of this system. The analysis focuses on the logical adequacy, heuristic power, notational convenience, and explanation support provided by the PROforma language. Results PROforma proved adequate as a language for the implementation of the clinical reasoning required by this project. However a lack of notational convenience led us to use UML activity diagrams, rather than PROforma process descriptions, to create the models that were used during the knowledge acquisition and analysis phases of the project. These UML diagrams were translated into PROforma during the implementation of the project. Conclusion The experience accumulated during this study highlighted the importance of structure preserving design, that is to say that the models used in the design and implementation of a knowledge-based system should be structurally similar to those created during knowledge acquisition and analysis. Ideally the same language should be used for all of these models. This means that great importance has to be attached to the notational convenience of these languages, by
Olivares Cortés, Sonia; Zacarías Hasbún, Isabel; González González, Carmen Gloria; Fonseca Morán, Lilian; Mediano Stoltze, Fernanda; Pinheiro Fernandes, Anna Christina; Rodríguez Osiac, Lorena
Food-Based Dietary Guidelines (FBDG) are usually accompanied by an image for dissemination and implementation. to design and validate an image to represent the variety and proportions of the new Chilean dietary guidelines, include foods high in critical nutrients that should be avoided and physical activity guidelines. a panel of experts tested seven graphics and selected three that were validated with 12 focus groups of people aged 10-14 and 20-40 years, of both sexes, from different socioeconomic groups and from both rural and urban areas. We analyzed the perception of variety and proportions of the food groups for daily intake and motivation for action in diet and physical activity. We utilized the METAPLAN method used previously in the validation of FBDG. the final image was a circle that showed the variety and proportions of each food group for daily consumption (in pictures), included physical activity guidelines in a strip around the middle of the circle and a rectangle towards of bottom of the image with examples of foods high in critical nutrients in black and white. The chosen picture was modified using input from participants and validated with three additional focus groups, improving its understanding and acceptance. most participants understood that the image represented the relationship between healthy eating and daily physical activity, correctly identifying the food groups for which increased intake was suggested and those groups in which intake should be reduced or avoided. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.
Al-Hussein, Fahad A
To use statistical control charts in a series of audits to improve the acceptance and consistant use of guidelines, and reduce the variations in prescription processing in primary health care. A series of audits were done at the main satellite of King Saud Housing Family and Community Medicine Center, National Guard Health Affairs, Riyadh, where three general practitioners and six pharmacists provide outpatient care to about 3000 residents. Audits were carried out every fortnight to calculate the proportion of prescriptions that did not conform to the given guidelines of prescribing and dispensing. Simple random samples of thirty were chosen from a sampling frame of all prescriptions given in the two previous weeks. Thirty six audits were carried out from September 2004 to February 2006. P-charts were constructed around a parametric specification of non-conformities not exceeding 25%. Of the 1081 prescriptions, the most frequent non-conformity was failure to write generic names (35.5%), followed by the failure to record patient's weight (16.4%), pharmacist's name (14.3%), duration of therapy (9.1%), and the use of inappropriate abbreviations (6.0%). Initially, 100% of prescriptions did not conform to the guidelines, but within a period of three months, this came down to 40%. A process of audits in the context of statistical process control is necessary for any improvement in the implementation of guidelines in primary care. Statistical process control charts are an effective means of visual feedback to the care providers.
AlMarshedi, Alaa; Wills, Gary; Ranchhod, Ashok
Gamification is the use of game elements and techniques in nongaming contexts. The use of gamification in health care is receiving a great deal of attention in both academic research and the industry. However, it can be noticed that many gamification apps in health care do not follow any standardized guidelines. This research aims to (1) present a set of guidelines based on the validated framework the Wheel of Sukr and (2) assess the guidelines through expert interviews and focus group sessions with developers. Expert interviews (N=6) were conducted to assess the content of the guidelines and that they reflect the Wheel of Sukr. In addition, the guidelines were assessed by developers (N=15) in 5 focus group sessions, where each group had an average of 3 developers. The guidelines received support from the experts. By the end of the sixth interview, it was determined that a saturation point was reached. Experts agreed that the guidelines accurately reflect the framework the Wheel of Sukr and that developers can potentially use them to create gamified self-management apps for chronic illnesses. Moreover, the guidelines were welcomed by developers who participated in the focus group sessions. They found the guidelines to be clear, useful, and implementable. Also, they were able to suggest many ways of gamifying a nongamified self-management app when they were presented with one. The findings suggest that the guidelines introduced in this research are clear, useful, and ready to be implemented for the creation of self-management apps that use the notion of gamification as described in the Wheel of Sukr framework. The guidelines are now ready to be practically tested. Further practical studies of the effectiveness of each element in the guidelines are to be carried out. ©Alaa AlMarshedi, Gary Wills, Ashok Ranchhod. Originally published in JMIR Serious Games (http://games.jmir.org), 12.05.2017.
Full Text Available Abstract Background As effective antibiotics are becoming a scarce resource, governmental regulation is needed to promote responsible use. Implementation of antibiotic stewardship and practice guidelines in health care facilities seems to be crucial to this effort. Empirical studies suggest, however, that guidelines have limited influence on health professionals’ behavior and practice. Barriers and facilitators to guideline implementability are much studied, but little attention has been given to health professionals’ perceptions of normative acceptability of guidelines as a condition for compliance. The aim of the present study was first, to examine if and how aspects potentially promoting acceptability and compliance among clinical target users were addressed during development of Norwegian national guidelines for antibiotic use in hospitals and second, to identify procedural characteristics of the development process that were perceived by target users to yield legitimate guidelines. Methods Qualitative deductive thematic analysis was used. A theoretical framework inspired by the AGREE II Instrument and the Accountability for reasonableness framework assisted data gathering and interpretation. Archival data was collected and used to detail the guideline development process. Semi-structured, in-depth interviews with eight clinicians with extensive knowledge of the guidelines were carried out. Results Guideline development was characterized by i broad agreement about scope and purpose, ii broad involvement of stakeholders in the development process, iii use of systematic methods to search for and apply evidence, iv easily identifiable and specific recommendations, v provision of tools on how to put recommendations into practice, and vi editorial independence. Several procedural characteristics were perceived by the interviewees as promoting guideline legitimacy; i diverse perspectives systematically involved in the process, ii accessibility
Feiring, Eli; Walter, Anne Berit
As effective antibiotics are becoming a scarce resource, governmental regulation is needed to promote responsible use. Implementation of antibiotic stewardship and practice guidelines in health care facilities seems to be crucial to this effort. Empirical studies suggest, however, that guidelines have limited influence on health professionals' behavior and practice. Barriers and facilitators to guideline implementability are much studied, but little attention has been given to health professionals' perceptions of normative acceptability of guidelines as a condition for compliance. The aim of the present study was first, to examine if and how aspects potentially promoting acceptability and compliance among clinical target users were addressed during development of Norwegian national guidelines for antibiotic use in hospitals and second, to identify procedural characteristics of the development process that were perceived by target users to yield legitimate guidelines. Qualitative deductive thematic analysis was used. A theoretical framework inspired by the AGREE II Instrument and the Accountability for reasonableness framework assisted data gathering and interpretation. Archival data was collected and used to detail the guideline development process. Semi-structured, in-depth interviews with eight clinicians with extensive knowledge of the guidelines were carried out. Guideline development was characterized by i) broad agreement about scope and purpose, ii) broad involvement of stakeholders in the development process, iii) use of systematic methods to search for and apply evidence, iv) easily identifiable and specific recommendations, v) provision of tools on how to put recommendations into practice, and vi) editorial independence. Several procedural characteristics were perceived by the interviewees as promoting guideline legitimacy; i) diverse perspectives systematically involved in the process, ii) accessibility and transparency of the rationales for decision
Yu, C.; Zielen, A.J.; Cheng, J.J. [and others
This manual presents information for implementing US Department of Energy (DOE) guidelines for residual radioactive material. It describes the analysis and models used to derive site-specific guidelines for allowable residual concentrations of radionuclides in soil and the design and use of the RESRAD computer code for calculating doses, risks, and guideline values. It also describes procedures for implementing DOE policy for reducing residual radioactivity to levels that are as low as reasonably achievable. Two new pathways, radon inhalation and soil ingestion, have been added to RESRAD. Twenty-seven new radionuclides have also been added, and the cutoff half-life for associated radionuclides has been reduced to six months. Other major improvements to the RESRAD code include the ability to run sensitivity analyses, the addition of graphical output, user-specified dose factors, updated databases, an improved groundwater transport model, optional input of a groundwater concentration and a solubility constant, special models for tritium and carbon-14, calculation of cancer incidence risk, and the use of a mouse with menus.
Yu, C.; Zielen, A.J.; Cheng, J.J.
This manual presents information for implementing US Department of Energy (DOE) guidelines for residual radioactive material. It describes the analysis and models used to derive site-specific guidelines for allowable residual concentrations of radionuclides in soil and the design and use of the RESRAD computer code for calculating doses, risks, and guideline values. It also describes procedures for implementing DOE policy for reducing residual radioactivity to levels that are as low as reasonably achievable. Two new pathways, radon inhalation and soil ingestion, have been added to RESRAD. Twenty-seven new radionuclides have also been added, and the cutoff half-life for associated radionuclides has been reduced to six months. Other major improvements to the RESRAD code include the ability to run sensitivity analyses, the addition of graphical output, user-specified dose factors, updated databases, an improved groundwater transport model, optional input of a groundwater concentration and a solubility constant, special models for tritium and carbon-14, calculation of cancer incidence risk, and the use of a mouse with menus
Full Text Available Purpose: Adherence to international antiemetic prophylaxis guidelines like those of ASCO can result in better control of chemotherapy-induced nausea and vomiting; however, the extent of implementation of such guidelines in India is unknown. Therefore, this survey was planned. Methods: This study was an anonymized cross-sectional survey approved by the ethics committee. Survey items were generated from the clinical questions given in the ASCO guidelines. The survey was disseminated through personal contacts at an oncology conference and via e-mail to various community oncology centers across India. The B1, B2, and B3 domains included questions regarding the optimal antiemetic prophylaxis for high, moderate, and low-minimal emetogenic regimens. Results: Sixty-six (62.9% of 105 responded and 65 centers (98.5% were aware of the published guidelines. The partial, full, and no implementation scores were 92.5%, 4.5%, and 3.0%, respectively. Full implementation was better for the low-minimal emetogenic regimens (34.8% than the highly emetogenic regimens (6.1%. The three most frequent reasons for hampered implementation of ASCO guidelines in routine chemotherapy practice cited by centers were a lack of sensitization (26 centers; 39.4%, lack of national guidelines (12 centers; 18.2%, and lack of administrative support (10 centers; 15.2%. Conclusion: Awareness regarding ASCO antiemetic guidelines is satisfactory in Indian oncology practices; however, there is a need for sensitization of oncologists toward complete implementation of these guidelines in their clinical practice.
Lawrence von Karsa
Full Text Available In Europe, as in many other regions of the world, breast cancer is a major cause of suffering and death. Early detection of breast cancer by systematic mammography screening can find lesions for which treatment is more effective and generally more favourable for quality of life. Comprehensive quality assurance guidelines for breast cancer screening based on mammography have been developed in the Europe Against Cancer programme with the aim of maximising screening benefits while minimising adverse effects, such as unnecessary examination or treatment resulting from false-positive screening tests. The present report provides an overview of the European experience in developing and implementing quality assurance guidelines for breast cancer screening. It highlights implications relevant to those regions of the world in which the burden of breast cancer in the coming years will make population-based screening an option for cancer control.
van Gils, Chantal W. M.; Koopman, Miriam; Mol, Linda; Redekop, William K.; Uyl-de Groot, Carin A.; Punt, Cornelis J. A.
Little is known about how well guidelines about adjuvant chemotherapy in colon cancer are followed in daily practice. We evaluated the current guideline, which is based on the MOSAIC trial, by examining implementation, treatment patterns and disease-free survival. We analysed a population-based
Becker, Annette; Held, Heiko; Redaelli, Marcus; Chenot, Jean F; Leonhardt, Corinna; Keller, Stefan; Baum, Erika; Pfingsten, Michael; Hildebrandt, Jan; Basler, Heinz-Dieter; Kochen, Michael M; Donner-Banzhoff, Norbert; Strauch, Konstantin
Cost-effectiveness analysis alongside a cluster randomized controlled trial. To study the cost-effectiveness of 2 low back pain guideline implementation (GI) strategies. Several evidence-based guidelines on management of low back pain have been published. However, there is still no consensus on the effective implementation strategy. Especially studies on the economic impact of different implementation strategies are lacking. This analysis was performed alongside a cluster randomized controlled trial on the effectiveness of 2 GI strategies (physician education alone [GI] or physician education in combination with motivational counseling [MC] by practice nurses)--both compared with the postal dissemination of the guideline (control group, C). Sociodemographic data, pain characteristics, and cost data were collected by interview at baseline and after 6 and 12 months. low back pain-related health care costs were valued for 2004 from the societal perspective. For the cost analysis, 1322 patients from 126 general practices were included. Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls. In addition, both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data. Trends in cost-effectiveness are visible but need to be confirmed in future studies. Researchers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the randomization success by reviewing non-cost parameters like clinical data alone.
Brink, M.; Babisch, W.; Belojevic, G.; Heroux, M.E.; Janssen, S.; Lercher, P.; Paviotti, M.; Pershagen, G.; Persson Waye, K.; Preis, A.; Stansfeld, S.; Van Den Berg, M.; Verbeek, J.
WHO Environmental Noise Guidelines focus on the WHO European Region and provide guidance to its Member States that is compatible with the noise indicators used in the EU Environmental Noise Directive. The Guidelines aim to serve as a reference for several target audiences, such as decision makers
Background: Performance measures are a key component of implementation, dissemination, and evaluation of evidence-based guidelines (EBGs). We developed performance measures for Emergency Medical Services (EMS) stakeholders to enable the implementatio...
Samayoa-Peláez, Maritza; Ayala, Nancy; Yadon, Zaida E; Heldal, Einar
Objective To assess whether the National Tuberculosis Program (NTP) guidelines for culture and drug sensitivity testing (DST) in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB) or previously treated TB, by documenting notification rates by department (geographic area), disease type and category, and culture and DST results. Methods This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases) and culture combined with DST (for previously treated patients) were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results There were 3 074 patients registered with TB (all forms), for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76%) were smear-positive pulmonary TB (PTB), 385 (14%) were smear-negative PTB, and 290 (10%) were extrapulmonary TB. There were 232 (8%) previously treated cases. Case notification rates (all forms) varied by department from 2-68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB). Only 21 (5%) of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23%) had a culture and 47 (20%) had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital), culture and DST was performed in new smear-negative PTB in 7 departments (32%) and in previously treated TB in 13 departments (59%). Conclusions Despite national guidelines, only 5% of smear-negative PTB cases had a culture and only 20% of
Full Text Available ABSTRACT Objective To assess whether the National Tuberculosis Program (NTP guidelines for culture and drug sensitivity testing (DST in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB or previously treated TB, by documenting notification rates by department (geographic area, disease type and category, and culture and DST results. Methods This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases and culture combined with DST (for previously treated patients were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results There were 3 074 patients registered with TB (all forms, for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76% were smear-positive pulmonary TB (PTB, 385 (14% were smear-negative PTB, and 290 (10% were extrapulmonary TB. There were 232 (8% previously treated cases. Case notification rates (all forms varied by department from 2–68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB. Only 21 (5% of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23% had a culture and 47 (20% had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital, culture and DST was performed in new smear-negative PTB in 7 departments (32% and in previously treated TB in 13 departments (59%. Conclusions Despite national guidelines, only 5% of smear-negative PTB cases had a culture and
Schreyer, A.G.; Ludwig, D.; Koletzko, S.; Hoffmann, J.C.; Preiss, J.C.; Zeitz, M.; Stange, E.; Herrlinger, K.R.
The recently updated German S3-guideline regarding the diagnosis and treatment of Crohn's disease incorporates several changes concerning the radiological approach compared to the former guideline. This article focuses on guideline-based radiological imaging techniques for patients with Crohn's disease. The new guideline is also compared to former European and German guidelines in the context of recently published radiological literature. (orig.)
Heskestad, Ben; Waterloo, Knut; Ingebrigtsen, Tor
The Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low...... compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention....
Full Text Available The case study research approach is widely used in a number of different ways within the information systems community. This paper focuses on positivist, deductive case study research in information systems. It provides clear definitions of important concepts in positivist case study research and illustrates these with an example research study. A critical analysis of the conduct and outcomes of two recently published positivist case studies is reported. One is a multiple case study that validated concepts in a framework for viewpoint development in requirements definition. The other is a single case study that examined the role of social enablers in enterprise resource planning systems implementation. A number of guidelines for successfully undertaking positivist case study research are identified including developing a clear understanding of key concepts and assumptions within the positivist paradigm; providing clear and unambiguous definitions of the units and interactions when using any theory; carefully defining the boundary of the theory used in the case study; using hypotheses rather than propositions in the empirical testing of theory; using fuzzy or probabilistic propositions in recognising that reality can never be perfectly known; selecting case studies carefully, particularly single case studies; and recognising that generalisation from positivist, single case studies is inherently different from generalisation from single experiments. When properly undertaken, positivist, deductive case study research is a valuable research approach for information systems researchers, particularly when used within pluralist research programs that use a number of different research approaches from different paradigms.
Kingma, Anna E C; van Stel, Henk F; Oudega, Ruud; Moons, Karel G M; Geersing, Geert-Jan
A clinical decision rule (CDR), combined with a negative D-dimer test, can safely rule out deep venous thrombosis (DVT) in primary care. This strategy is recommended by guidelines, yet uptake by GPs is low. To evaluate a multi-faceted implementation strategy aimed at increased use of the guideline recommended CDR plus D-dimer test in primary care patients with suspected DVT. This multi-faceted implementation strategy consisted of educational outreach visits, financial reimbursements and periodical newsletters. 217 Dutch GPs (implementation group) received this strategy and included patients. Effectiveness was measured through the following patient-level outcomes: (i) proportion of non-referred patients, (ii) proportion of missed DVT cases within this group and (iii) the proportion of patients in whom the guideline was applied incorrectly. Implementation outcomes ('acceptability', 'feasibility', 'fidelity' and 'sustainability') were assessed with an online questionnaire. Patient-level outcomes were compared with those of patients included by 450 GPs, uninformed about the study's purposes providing information about usual care. 336 (54%) of 619 analyzable implementation group patients were not referred, missing 6 [1.8% (95% confidence interval 0.7% to 3.9%)] DVT cases. Incorrect guideline use was observed in 199 patients (32%). Self-reported acceptability, feasibility and expected sustainability were high. Guideline use increased from 42% to an expected continuation of use of 91%. Only 32 usual care GPs included 62 patients, making formal comparison unreliable. This multi-faceted implementation strategy safely reduced patient referral to secondary care, despite frequently incorrect application of the guideline and resulted in high acceptability, feasibility and expected sustainability. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Onion, C W; Bartzokas, C A
When attempting to implement evidence-based medicine, such as through clinical guidelines, we often rely on passive educational tactics, for example didactic lectures and bulletins. These methods involve the recipient in relatively superficial processing of information, and any consequent attitude changes can be expected to be short-lived. However, active methods, such as practice-based discussion, should involve recipients in deep processing, with more enduring attitude changes. In this experiment, the aim was to assess the efficacy of an active strategy at promoting deep processing and its effectiveness, relative to a typical passive method, at changing attitudes between groups of GPs over 12 months across an English Health District. All 191 GPs operating from 69 practices in the Wirral Health District of Northwest England were assigned, with minimization of known confounding variables, to three experimental groups: active, passive and control. The groups were shown to have similar learning styles. The objective of the study was to impart knowledge of best management of infections as captured in a series of locally developed clinical guidelines. The passive group GPs were given a copy of the guidelines and were invited to an hour-long lecture event. The GPs in the deep group were given a copy of the guidelines and were invited to engage in an hour-long discussion about the guideline content at their own premises. The control group received neither the guidelines nor any educational contact regarding them. Three months before and 12 months after the interventions, all GPs were sent a postal questionnaire on their preferred empirical antibiotic for 10 common bacterial infections. The responses were compared in order to ascertain whether increased knowledge of best clinical practice was evident in each group. Seventy-five per cent (144/191) of GPs responded to the pre-intervention questionnaire, 62 % (119/191) post-intervention. Thirty-four per cent (22/64) of GPs
Luis Joyanes Aguilar
Full Text Available Due to the significant increase in threats, attacks and vulnerabilities that affect the Web in recent years has resulted the development and implementation of pools and methods to ensure security measures in the privacy, confidentiality and data integrity of users and businesses. Under certain circumstances, despite the implementation of these tools do not always get the flow of information which is passed in a secure manner. Many of these security tools and methods cannot be accessed by people who have disabilities or assistive technologies which enable people to access the Web efficiently. Among these security tools that are not accessible are the virtual keyboard, the CAPTCHA and other technologies that help to some extent to ensure safety on the Internet and are used in certain measures to combat malicious code and attacks that have been increased in recent times on the Web. Through the implementation of intelligent systems can detect, recover and receive information on the characteristics and properties of the different tools and hardware devices or software with which the user is accessing a web application and through analysis and interpretation of these intelligent systems can infer and automatically adjust the characteristics necessary to have these tools to be accessible by anyone regardless of disability or navigation context. This paper defines a set of guidelines and specific features that should have the security tools and methods to ensure the Web accessibility through the implementation of intelligent systems.
Environmental liability guideline, the environmental damage law, execution and implementation deficiencies. A study on the structural execution suitability; Die Umwelthaftungsrichtlinie, das Umweltschadensgesetz, Vollzugs- und Implementationsdefizite. Eine Untersuchung zur strukturellen Vollzugseignung
Is there an effective liability for environmental damage? The sinking of the tanker ''Exxon Valdez'' has brought about an innovation in US environmental law. The dying of large areas of great forest and the Sandoz case have inspired thought in Germany. Who is responsible for the damages already incurred? How are damages to be replaced? Can environmental damage be quantified? For the replacement of damages, legal liability systems have been created, which are primarily of civil law, the compensation of damages between two private parties. In Germany there is a public liability system, which places the party ''generality'' against the operator of plants as an opponent and demands compensation, restoration of natural species and habitats, water bodies and soils. In 2004, the Directive on environmental liability with regard to the prevention and remedying of environmental damage (the Environmental Liability Directive or UHRL), was adopted. In Germany, the appropriate implementation took place in 2007 with the Environmental Damages Act (USchadG). A comparison with US environmental legislation and an overview of the implementation of the Environmental Liability Directive in the Member States completes the study. Julia-Carolina Holz gives a detailed look at the fundamentals and research status of enforcement deficits and examines the enforcement of the Environmental Liability Directive as well as the Environmental Damages Act.
Timen, Aura; Hulscher, Marlies E J L; Rust, Laura; van Steenbergen, Jim E; Akkermans, Reinier P; Grol, Richard P T M; van der Meer, Jos W M
Communicable disease crises can endanger the health care system and often require special guidelines. Understanding reasons for nonadherence to crisis guidelines is needed to improve crisis management. We identified and measured barriers and conditions for optimal adherence as perceived by 4 categories of health care professionals. In-depth interviews were performed (n = 26) to develop a questionnaire for a cross-sectional survey of microbiologists (100% response), infection preventionists (74% response), public health physicians (96% response), and public health nurses (82% response). The groups were asked to appraise barriers encountered during 4 outbreaks (severe acute respiratory syndrome [SARS], Clostridium difficile ribotype 027, rubella, and avian influenza) according to a 5-point Likert scale. When at least 33% of the participants responded "strongly agree," "agree," or "rather agree than disagree," a barrier was defined as "often experienced." The common ("generic") barriers were included in a univariate and multivariate model. Barriers specific to the various groups were studied as well. Crisis guidelines were found to have 4 generic barriers to adherence: (1) lack of imperative or precise wording, (2) lack of easily identifiable instructions specific to each profession, (3) lack of concrete performance targets, and (4) lack of timely and adequate guidance on personal protective equipment and other safety measures. The cross-sectional study also yielded profession-specific sets of often-experienced barriers. To improve adherence to crisis guidelines, the generic barriers should be addressed when developing guidelines, irrespective of the infectious agent. Profession-specific barriers require profession-specific strategies to change attitudes, ensure organizational facilities, and provide an adequate setting for crisis management. Copyright © 2010 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights
Sheehan, Sharon R
OBJECTIVE: Caesarean section is one of the most commonly performed major operations on women worldwide. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. Various clinical guidelines address oxytocin use at the time of caesarean section. We previously reported wide variation in practice amongst clinicians in the United Kingdom in the use of oxytocin at caesarean section. The aim of this current study was to determine whether the variation in approach is universal across the individual countries of Great Britain and Ireland and whether this reflects differences in interpretation and implementation of clinical practice guidelines. STUDY DESIGN: We conducted a survey of practice in the five individual countries of Great Britain and Ireland. A postal questionnaire was sent to all lead consultant obstetricians and anaesthetists with responsibility for the labour ward. We explored the use of oxytocin bolus and infusion, the measurement of blood loss at caesarean section and the rates of major haemorrhage. Existing clinical guidelines from the National Institute for Clinical Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and ALSO (Advanced Life Support in Obstetrics) were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section. RESULTS: The response rate was 82% (391 respondents). Use of a 5 IU oxytocin bolus was reported by 346 respondents (85-95% for individual countries). In some countries, up to 14% used a 10 IU oxytocin bolus despite recommendations against this. Routine use of an oxytocin infusion varied greatly between countries (11% lowest-55% highest). Marked variations in choice of oxytocin regimens were noted with inconsistencies in the country-specific recommendations, e.g. NICE (which covers England and Wales) recommends a 30 IU oxytocin infusion over 4h, but only 122 clinicians (40%) used this. CONCLUSIONS
Yasini, Mobin; Ebrahiminia, Vahid; Duclos, Catherine; Venot, Alain; Lamy, Jean-Baptiste
Laboratory medicine is responsible for an important part of hospital expenditure. Providing appropriate decision support to laboratory test requesters at the point of care is one of the main incentives for implementing laboratory guidelines, which can improve medical care. Laboratory guidelines developed by local experts in the Parisian region and two national guidelines for dyslipidemia were analyzed to extract test ordering recommendations. Clinical conditions which can be a trigger to order or not to order laboratory tests were extracted and mapped with ICD10 and SNOMED CT: 43.1% of clinical conditions were matched by ICD10 whereas SNOMED CT covered 80.1% of these conditions. For the non-mapped conditions, the main problem was found to be the ambiguity of the terms used in the guidelines. Ordinal characteristics of some clinical conditions and using terms more specific than SNOMED CT were other causes of mapping failure. Applying consistent and explicit concepts in the development of guidelines would lead to better implementation. By resolving the guideline ambiguity, SNOMED CT is a good choice and covers almost all of the clinical conditions in laboratory guidelines which are needed to implement in a Clinical Decision Support System.
E. L. Mc Goldrick
Full Text Available Abstract Background The ineffective implementation of evidence based practice guidelines can mean that the best health outcomes are not achieved. This study examined the barriers and enablers to the uptake and implementation of the new bi-national (Australia and New Zealand antenatal corticosteroid clinical practice guidelines among health professionals, using the Theoretical Domains Framework. Methods Semi-structured interviews or online questionnaires were conducted across four health professional groups and three district health boards in Auckland, New Zealand. The questions were constructed to reflect the 14 behavioural domains from the Theoretical Domains Framework. Relevant domains were identified by the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour using thematic analysis. The influence of health professional group and organisation on the different barriers and enablers identified were explored. Results Seventy-three health professionals completed either a semi-structured interview (n = 35 or on-line questionnaire (n = 38. Seven behavioural domains were identified as overarching enablers: belief about consequences; knowledge; social influences; environmental context and resource; belief about capabilities; social professional role and identity; and behavioural regulation. Five behavioural domains were identified as overarching barriers: environmental context and resources; knowledge; social influences; belief about consequences; and social professional role and identity. Differences in beliefs between individual health professional groups were identified within the domains: belief about consequences; social professional role and identity; and emotion. Organisational differences were identified within the domains: belief about consequences; social influences; and belief about capabilities. Conclusion This study has identified some of the
Full Text Available Cameron J Phillips,1–3 David L Gordon3,4 1Division of Pharmacy, SA Pharmacy, Flinders Medical Centre, Bedford Park, 2School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, 3Department of Microbiology and Infectious Diseases, School of Medicine, Flinders University, Adelaide, 4Department of Microbiology and Infectious Diseases, SA Pathology, Flinders Medical Centre, Bedford Park, SA, Australia Background: Vancomycin is the antibiotic of choice for the treatment of serious infections such as methicillin-resistant Staphylococcus aureus (MRSA. Inappropriate prescribing of vancomycin can lead to therapeutic failure, antibiotic resistance, and drug toxicity. Objective: To examine the effectiveness of pharmacist-led implementation of a clinical practice guideline for vancomycin dosing and monitoring in a teaching hospital. Methods: An observational pre–post study design was undertaken to evaluate the implementation of the vancomycin guideline. The implementation strategy principally involved education, clinical vignettes, and provision of pocket guidelines to accompany release of the guideline to the hospital Intranet. The target cohort for clinical behavioral change was junior medical officers, as they perform the majority of prescribing and monitoring of vancomycin in hospitals. Assessment measures were recorded for vancomycin prescribing, therapeutic drug monitoring, and patient outcomes. Results: Ninety-nine patients, 53 pre- and 46 post-implementation, were included in the study. Prescribing of a loading dose increased from 9% to 28% (P=0.02, and guideline adherence to starting maintenance dosing increased from 53% to 63% (P=0.32. Dose adjustment by doctors when blood concentrations were outside target increased from 53% to 71% (P=0.12, and correct timing of initial concentration measurement increased from 43% to 57% (P=0.23. Appropriately timed trough concentrations improved from 73% to 81% (P=0.08. Pre-dose (trough
Full Text Available Abstract Background The protection and promotion of breastfeeding is considered a priority in Europe where only 22% of infants less than 6 months old are exclusively breastfed. In Spain this percentage reaches 24.8% but in our city it falls to 18.26%. Various studies emphasise that the improvement of these results should be based upon the training of health professionals. Following the recommendations of a breastfeeding guide can modify the practice of health professionals and improve results with respect to exclusively or predominatly breastfed children at 6 months of age. Method/Design This study involves a community based cluster randomized trial in primary healthcare centres in Leganés (Madrid, Spain. The project aims to determine whether the use of an implementation strategy (including training session, information distribution, opinion leader of a breastfeeding guideline in primary care is more effective than usual diffusion. The number of patients required will be 240 (120 in each arm. It will be included all the mothers of infants born during the study period (6 months who come to the health centre on the first visit of the child care programme and who give their consent to participate. The main outcome variable is the exclusive o predominant breastfeeding at 6 moths of age.. Main effectiveness will be analyzed by comparing the percentage of infants with exclusive or predominant breastfeeding at 6 months between the intervention group and the control group. All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. Discussion Strategies need to be found which facilitate the giving of effective advice on breastfeeding by professionals and which provide support to women during the breastfeeding period. By applying the guide
Yoong, Sze Lin; Jones, Jannah; Marshall, Josephine; Wiggers, John; Seward, Kirsty; Finch, Meghan; Fielding, Alison; Wolfenden, Luke
Childcare services represent a key setting to implement nutritional interventions to support the development of healthy eating behaviours in young children. Childcare-specific nutritional guidelines outlining recommendations for provision of food in care have been developed. Despite this, research suggests that few childcare services currently implement these guidelines. This study aimed to examine the impact of providing printed educational materials on childcare service cooks' intentions to use nutritional guidelines and provide fruit and vegetables on their menu. A randomised controlled trial was conducted with 77 childcare services (38 control and 39 intervention). Intervention service cooks were mailed a two-page educational material together with a menu planning checklist. Intervention development and evaluation was guided by the theory of planned behaviour. Outcome data assessing intentions to use nutritional guidelines and serves of fruit and vegetables provided on menus (primary outcomes) as well as secondary outcomes (attitudes, behavioural regulation and social norms) were collected via a telephone interview with cooks. Relative to the comparison group, cooks in the intervention arm had significantly higher intentions to use the guidelines (p value 0.0005), accompanied by significant changes in perceived behavioural control (p value 0.0008) and attitudes (p value 0.0071). No significant difference in serves of fruit (p value 0.7278) and vegetables (p value 0.0573) was observed. The use of educational materials can improve childcare service cooks' intentions to use nutritional guidelines; however, as a standalone strategy, it may not improve provision of food on menus.
Evidence from randomized controlled trials (RCTs) plays a powerful role in today's healthcare industry. At the same time, it is important that multiple types of evidence contribute to music therapy's knowledge base and that the dialogue of clinical effectiveness in music therapy is not dominated by the biomedical hierarchical model of evidence-based practice. Whether or not one agrees with the hierarchical model of evidence in the current healthcare climate, RCTs can contribute important knowledge to our field. Therefore, it is important that music therapists are prepared to design trials that meet current methodological standards and, equally important, are able to respond appropriately to those design aspects that may not be feasible in music therapy research. To provide practical guidelines to music therapy researchers for the design and implementation of RCTs as well as to enable music therapists to be well-informed consumers of RCT evidence. This article reviews key design aspects of RCTs and discusses how to best implement these standards in music therapy trials. A systematic presentation of basic randomization methods, allocation concealment strategies, issues related to blinding in music therapy trials and strategies for implementation, the use of treatment manuals, types of control groups, outcome selection, and sample size computation is provided. Despite the challenges of meeting all key design demands typical of an RCT, it is possible to design rigorous music therapy RCTs that accurately estimate music therapy treatment benefits.
Olivares, Sonia; Zacarías, Isabel; González, Carmen Gloria
Implementation of the updated Food Based Dietary Guidelines (FBDG) for the Chilean population requires the design of innovative strategies and effective. To determine motivations and barriers for children and mothers of preschool-age children to follow new FBDG messages, aiming to identify challenges and opportunities for designing effective communication and implementation strategies. A qualitative study based on 12 focus groups of 9 to 13 age children and 6 focus groups of mothers of preschool-age children, living in the north, central and south regions of the country, to analyze their reaction to each one of the 2013 FBDG messages. Answers of children and mothers did not show differences by gender (in the case of the children) or region of the country. Results show the most frequent and representative comments regarding each message. Challenges to reducing the consumption of foods high in energy, fat, sugar and salt include advertisements and plentiful supply and low prices for these types of foods, both in the school environment and on the street. Opportunities identified included the advertisement of fruits, vegetables and dairy products to promote their consumption, as well as the coming implementation of Law 20.606, which is expected to be an effective way to support this initiative. The results of this study show that the design of strategies based on values, desires and needs of different groups will contribute to optimizing the implementation of the 2013 Chilean FBDG. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.
Halsnaes, K.; Painuly, J.P.; Turkson, J.; Meyer, H.J.; Markandya, A.
This document is a summary version of the methodological guidelines for climate change mitigation assessment developed as part of the Global Environment Facility (GEF) project Economics of Greenhouse Gas Limitations; Methodological Guidelines. The objectives of this project have been to develop a methodology, an implementing framework and a reporting system which countries can use in the construction of national climate change mitigation policies and in meeting their future reporting obligations under the FCCC. The methodological framework developed in the Methodological Guidelines covers key economic concepts, scenario building, modelling tools and common assumptions. It was used by several country studies included in the project. (au) 13 refs.
Menke J Michael
Full Text Available Abstract Background This paper presents findings from the Tobacco Control in Arizona Healthcare Systems Survey, conducted in 2000. The purpose of the survey was to assess the status of Arizona healthcare systems' awareness and implementation of tobacco cessation and prevention measures. Methods The 20-item survey was developed by The University of Arizona HealthCare Partnership in collaboration with the Arizona Department of Health Services Bureau of Tobacco Education and Prevention. It was mailed to representatives of Arizona's 40 healthcare systems, including commercial and Medicare managed care organizations, "managed Medicaid" organizations, Veterans Affairs Health Care Systems, and Indian Health Service Medical Centers. Thirty-three healthcare systems (83% completed the survey. Results The majority of healthcare systems reported awareness of at least one tobacco cessation and prevention clinical practice guideline, but only one third reported full guideline implementation. While a majority covered some form of behavioral therapy, less than half reported covering tobacco treatment medications. "Managed Medicaid" organizations administered through the Arizona Health Care Cost Containment System were significantly less likely to offer coverage for behavioral therapy and less likely to cover pharmacotherapy than were their non-Medicaid counterparts in managed care, Veterans Affairs Health Care Systems and Indian Health Service Medical Centers. Conclusion Arizona healthcare system coverage for tobacco cessation in the year 2000 was comparable to national survey findings of the same year. The findings that only 10% of "Managed Medicaid" organizations covered tobacco treatment medication and were significantly less likely to cover behavioral therapy were important given the nearly double smoking prevalence among Medicaid patients. Throughout the years of the program, the strategic plan of the Arizona Department of Health Services Bureau of Tobacco
Colleselli, V; Nell, T; Bartosik, T; Brunner, C; Ciresa-Koenig, A; Wildt, L; Marth, C; Seeber, B
To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period. A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36-48 h. We followed-up with our patients using a written questionnaire. 167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive. The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.
Dunne, Jonathan A; Wormald, Justin C R; Ghedia, Reshma; Soldin, Mark
National guidelines for commissioning of body contouring surgery (BCS) following massive weight loss (MWL) in England were published in 2014. Nearly three-quarters of patients who have MWL seek BCS; however, access is known to vary according to the region. The aim of national guidelines was to standardise access. The purpose of this study was to determine implementation of the national guidelines by clinical commissioning groups (CCGs) in England. A cross-sectional, web-based survey was sent to all CCG chairs in England. Of 211 potential respondents, 108 completed the survey or provided funding guidelines (response rate = 52%). Eight CCGs (7%) had implemented the guidelines. A total of 69 CCGs were aware of the new guidelines (64%), and 66 CCGs stated that they fund BCS after MWL (61%). A total of 81 CCGs (75%) identified local funding guidelines, while 15 CCGs (14%) cited individual funding requests (IFRs) as the means of accessing funding. To improve patient access to BCS; 58 of 65 respondents (89%) stated cost-effectiveness, whereas 56 of 75 respondents (75%) thought patient-reported outcome measures were key. Qualitative data to improve access included an integrated pathway from bariatric surgery to BCS, an improved evidence base and greater CCG finances. One CCG stated that it cannot afford to fund cosmetic procedures. The purpose of national guidelines was to simplify the pathway to BCS after MWL and create fair distribution of funds across the country to needy patients; however, their uptake has been poor. Access to funding for BCS across England varies according to the location. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Rutten, Geert M; Harting, Janneke; Bartholomew, Leona K; Braspenning, Jozé C; van Dolder, Rob; Heijmans, Marcel Fgj; Hendriks, Erik Jm; Kremers, Stef Pj; van Peppen, Roland Ps; Rutten, Steven Tj; Schlief, Angelique; de Vries, Nanne K; Oostendorp, Rob Ab
Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.
Kottner, Jan; Audigé, Laurent; Brorson, Stig
Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need ......, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies....
Horak, Rachel E A; Merkel, Susan; Chang, Amy
A number of national reports, including Vision and Change in Undergraduate Biology Education: A Call to Action, have called for drastic changes in how undergraduate biology is taught. To that end, the American Society for Microbiology (ASM) has developed new Curriculum Guidelines for undergraduate microbiology that outline a comprehensive curriculum for any undergraduate introductory microbiology course or program of study. Designed to foster enduring understanding of core microbiology concepts, the Guidelines work synergistically with backwards course design to focus teaching on student-centered goals and priorities. In order to qualitatively assess how the ASM Curriculum Guidelines are used by educators and learn more about the needs of microbiology educators, the ASM Education Board distributed two surveys to the ASM education community. In this report, we discuss the results of these surveys (353 responses). We found that the ASM Curriculum Guidelines are being implemented in many different types of courses at all undergraduate levels. Educators indicated that the ASM Curriculum Guidelines were very helpful when planning courses and assessments. We discuss some specific ways in which the ASM Curriculum Guidelines have been used in undergraduate classrooms. The survey identified some barriers that microbiology educators faced when trying to adopt the ASM Curriculum Guidelines, including lack of time, lack of financial resources, and lack of supporting resources. Given the self-reported challenges to implementing the ASM Curriculum Guidelines in undergraduate classrooms, we identify here some activities related to the ASM Curriculum Guidelines that the ASM Education Board has initiated to assist educators in the implementation process.
Loyola-Sanchez, Adalberto; Richardson, Julie; Pelaez-Ballestas, Ingris; Sánchez, José Guadalupe; González, Martha Alicia; Sánchez-Cruz, Juan; Jiménez-Baez, María Valeria; Nolasco-Alonso, Nancy; Alvarado, Idolina; Rodríguez-Amado, Jacqueline; Alvarez-Nemegyei, José; Wilson, Mike G
To evaluate the implementability of the "2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care" within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2). Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques. Reviewers' agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients' beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline. The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.
Van Spall, Harriette G C; Shanbhag, Deepti; Gabizon, Itzhak; Ibrahim, Quazi; Graham, Ian D; Harlos, Karen; Haynes, R Brian; Connolly, Stuart J
The uptake of Clinical Practice Guideline (CPG) recommendations that improve outcomes in heart failure (HF) remains suboptimal. We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations, those with clear evidence that benefits outweigh the risks. We will use American, Canadian and European HF guidelines as our reference. We will conduct a literature search in the databases of MEDLINE, EMBASE, HEALTHSTAR, CINAHL, Cochrane Library, Campbell Collaboration, Joanna Briggs Institute Evidence Based Practice, Centre for Reviews and Dissemination and Evidence Based Practice Centres. We will include prospective studies evaluating implementation interventions aimed at improving uptake of class I CPG recommendations in HF. We will extract data in duplicate. We will classify interventions according to their level of application (ie, provider, organisation, systems level) and common underlying characteristics (eg, education, decision-support, financial incentives) using the Cochrane Effective Practice and Organisation of Care Taxonomy. We will assess the impact of the intervention on adherence to the CPGs. Outcomes will include proportion of eligible patients who were: prescribed a CPG-recommended pharmacological treatment; referred for device consideration; provided self-care education at discharge; and provided left ventricular function assessment. We will include clinical outcomes such as hospitalisations, readmissions and mortality, if data is available. We will identify the common elements of successful and failing interventions, and examine the context in which they were applied, using the Process Redesign contextual framework. We will synthesise the results narratively and, if appropriate, will pool results for meta-analysis. In this review, we will assess the impact of implementation strategies and contextual factors on physician adherence to HF CPGs. We will explore why some interventions may
MacLennan, Sara J; MacLennan, Steven; Bex, Axel; Catto, James W F; De Santis, Maria; Glaser, Adam W; Ljungberg, Borje; N'Dow, James; Plass, Karin; Trapero-Bertran, Marta; Van Poppel, Hendrik; Wright, Penny; Giles, Rachel H
Effective stakeholder integration for guideline development should improve outcomes and adherence to clinical practice guidelines. Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Zamora, Gerardo; Meneses, Daniela; De-Regil, Luz Maria; Neufeld, Lynnette; Peña-Rosas, Juan Pablo; Sinisterra, Odalis Teresa
The World Health Organization (WHO) follows a complex and rigorous process to develop global guidelines. With regard to nutrition-related guidelines, the joint participation of national authorities from Member States and their partners, including those of the social economy, is key to strengthening the process of evidence-informed guideline development and the subsequent implementation as part of national public health strategies. WHO puts forward a series of tools that can assist national authorities on health and social development in the elaboration of evidence-informed policies, considering their pertinence, relevance and implementability. This adoption and adaptation process must consider equity in order to avoid widening existing inequities. WHO global nutrition guidelines contribute to the effective implementation of nutrition interventions in Member States. Two experiences of implementation, one in Panama and one in Peru, exemplify this process. The paper ends by suggesting a deeper understanding and utilization of implementation research during programmes to identify what factors ensure effective interventions, appropriate scale up strategies and greater health equity.
Spitaels, D.; Vankrunkelsven, P.; Desfosses, J.; Luyten, F.; Verschueren, S.; Assche, D. Van; Aertgeerts, B.; Hermens, R.P.
RATIONALE, AIMS AND OBJECTIVES: Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and facilitators in current care were investigated. METHODS: Eleven patients with knee OA were extensively
Curley, Michael; Josey, Lawrence; Lucas, Robyn; Dear, Keith; Taylor, Bruce V.; Coulthard, Alan; Ausimmune Investigator Group
Multiple sclerosis (MS) is a debilitating disease that causes significant morbidity within a young demographic. Diagnostic guidelines for MS have evolved, and imaging has played an increasingly important role in diagnosis over the last two decades. For imaging to contribute to diagnosis in a meaningful way, it must be reproducible. Consensus guidelines for MRI in MS exist to define correct sequence type and imaging technique, but it is not clear to what extent they are followed. This study reviewed MRI studies performed on Australian individuals presenting with a first clinical diagnosis of central nervous system demyelination (FCD) for adherence to published guidelines and discussed practical implementation of MS guidelines in light of recent updates. The Ausimmune study was a prospective case control study of Australian participants presenting with FCD from 2003 to 2006. Baseline cranial and spinal cord MRI studies of 226 case participants from four separate Australian regions were reviewed. MRI sequences were classified according to anatomical location, slice plane, tissue weighting and use of gadolinium-containing contrast media. Results were compared with the 2003 Consortium of Multiple Sclerosis Centres MRI protocol for the diagnosis of MS. The composition of core cranial MRI sequences performed varied across the 226 scans. Of the studies, 91% included sagittal fluid attenuated inversion recovery (FLAIR) sequences. Cranial axial T2-weighted, axial FLAIR and axial proton density-weighted sequences were performed in 88%, 60% and 16% (respectively) of scans. Only 25% of the studies included a T1-weighted contrast-enhanced sequence. Concordance with the guidelines in all sequences was very low (2). Only a small number of MRI investigations performed included all of the sequences stipulated by consensus guidelines. This is likely due to poor awareness in the imaging community of the guidelines and the rationale behind certain sequences. Radiologists with a sub
... Updated American Veterinary Medical Association Guidelines for the Euthanasia of Animals: 2013 Edition... for the Euthanasia of Animals: 2013 Edition (Guidelines). The NIH is seeking input from the public on... updated AVMA Guidelines for the Euthanasia of Animals: 2013 Edition must be submitted electronically at...
Gray, Amy Z; Soukaloun, Douangdao; Soumphonphakdy, Bandith
Strategies to improve the quality of hospital care are needed if ongoing gains in child health and survival are to be made. We previously reported on improvements in the quality of case management in hospitals following a guideline-based intervention in Lao PDR, with variation in the degree of change achieved between clinical conditions. This study aims to understand the factors that influenced the uptake of the guideline-based intervention, and its impact on care. This qualitative study was embedded in a mixed-methods evaluation of guideline implementation in nine hospitals in Lao PDR. Focus groups and individual interviews were conducted with 70 health staff from central, provincial, and district hospitals. The interview guide was based on the Theoretical Domains Framework. Inductive content analysis was performed on interview transcripts to identify themes, supported by field notes from the intervention. Findings were triangulated against previously reported quantitative outcomes using driver diagrams. Key influences on guidelines uptake related to the guideline and intervention (filling a void, physical accessibility, comprehensibility, training in guideline use), health staff (behavior regulation, trust in guidelines, and beliefs about consequences), and the environment (social influences particularly consensus and incorporation into clinical norms). The major barrier was family preference for treatments in conflict with guideline recommendations. This study identifies contextual factors that explain, as well as validate previously identified improvements in care following guideline implementation in Lao PDR. It provides novel understanding of why the same intervention may have a differential impact on different clinical conditions.
Luitjes, S.H.E.; Mesri, K; Wouters, M
strategy of professional audit and feedback. In this study a process evaluation of BOS has been done, analyzing its efficiency, barriers and formulate improvement points.OBJECTIVES: Gynecologists, residents and clinical midwives from seven hospitals using BOS were asked to fill in the questionnaire...... by the respondents were mainly regarding the lay-out. Most respondents (85.3%) found it useful to make a computer based support system for other guidelines and 79.4% would also use this.CONCLUSION: BOS is regarded suitable as an instrument for implementing guidelines and respondents find it useful to develop...
Full Text Available This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI 29 to 104% or 29% (95% CI 5 to 60% in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health
Hamada, Sophie Rym; Gauss, Tobias; Pann, Jakob; Dünser, Martin; Leone, Marc; Duranteau, Jacques
available resources. Deviations from guidelines are frequent, differ from region to region and are dependent upon specialty training. Further efforts are required to provide consensus guidelines and to improve their implementation across European countries.
Hansen, C. R.; Bertelsen, Anders; Zukauskaite, R.
of volume of CTV1 for most institutions which previously used different margins. Change in CTV1 volume definition could influence the risk and time evolution of adverse effects e.g. mucositis. This study investigates change in acute response during RT in a centre where GTV to CTV1 margin was increased from......Purpose/Objective: New national guidelines (GL) for radiotherapy (RT) of head and neck cancer (HNC) were implemented at the beginning of 2013. One purpose of the new GL was to nationally standardise the expansion from GTV to high risk CTV (CTV1). This standardisation has resulted in change...... endpoints were dichotomized, grade 0- 1 vs 2+ or 0-2 vs 3+. Potential change in actuarial cumulative incidence (One minus the Kaplan Meier estimator) of mucositis was tested using the log-rank test. To stratify for the potential effect between non-accelerated (5 fx/w) and accelerated (6/10 fx/w) treatments...
Wlodaver, A; Blunt, M; Satnes, K; Escobedo, M; Hallford, G; Szyld, E
To evaluate the impact of implemented protocol changes on delivery room interventions and very low birth weight (VLBW) health outcomes. Retrospective study comparing birth characteristics, interventions and health outcomes of VLBW infants born in a tertiary care center before (calendar years 2008 to 2009) and after (calendar years 2012 to 2013) implementing new protocols using Chi-square analyses. Four hundred and nine were born before and 303 after changes were implemented. Postimplementation infants had more use of antenatal steroids (P=0.02), gestational age ⩽24 weeks (P=0.03) and birth weights between 501 and 750 g (P=0.04) and less oxygen administration (P=0.002), face mask ventilation (P=0.0001), surfactant use (P=0.0001), chest compressions (P=0.0001), intubation (P=0.002), epinephrine use (P=0.011), hypothermia (P=0.0001) and discharges home on supplemental oxygen (P=0.05). Changes creating a new delivery team, adopting new delivery practice guidelines and updating delivery room equipment resulted in positive outcomes for delivery room practices and patient outcomes.
Jensen, Maj-Britt; Laenkholm, Anne-Vibeke; Offersen, Birgitte V
BACKGROUND: Since 40 years, Danish Breast Cancer Cooperative Group (DBCG) has provided comprehensive guidelines for diagnosis and treatment of breast cancer. This population-based analysis aimed to describe the plurality of modifications introduced over the past 10 years in the national Danish...... guidelines for the management of early breast cancer. By use of the clinical DBCG database we analyze the effectiveness of the implementation of guideline revisions in Denmark. METHODS: From the DBCG guidelines we extracted modifications introduced in 2007-2016 and selected examples regarding surgery......, radiotherapy (RT) and systemic treatment. We assessed introduction of modifications from release on the DBCG webpage to change in clinical practice using the DBCG clinical database. RESULTS: Over a 10-year period data from 48,772 patients newly diagnosed with malignant breast tumors were entered into DBCG...
Mc Sharry, J; Murphy, P J; Byrne, M
Decreased sexual activity and sexual problems are common among people with cardiovascular disease, negatively impacting relationship satisfaction and quality of life. International guidelines recommend routine delivery of sexual counselling to cardiac patients. The Cardiac Health and Relationship Management and Sexuality (CHARMS) baseline study in Ireland found, similar to international findings, limited implementation of sexual counselling guidelines in practice. The aim of the current study was to develop the CHARMS multi-level intervention to increase delivery of sexual counselling by healthcare professionals. We describe the methods used to develop the CHARMS intervention following the three phases of the Behaviour Change Wheel approach: understand the behaviour, identify intervention options, and identify content and implementation options. Survey (n = 60) and focus group (n = 14) data from two previous studies exploring why sexual counselling is not currently being delivered were coded by two members of the research team to understand staff's capability, opportunity, and motivation to engage in the behaviour. All potentially relevant intervention functions to change behaviour were identified and the APEASE (affordability, practicability, effectiveness, acceptability, side effects and equity) criteria were used to select the most appropriate. The APEASE criteria were then used to choose between all behaviour change techniques (BCTs) potentially relevant to the identified functions, and these BCTs were translated into intervention content. The Template for Intervention Description and Replication (TIDieR) checklist was used to specify details of the intervention including the who, what, how and where of proposed intervention delivery. Providing sexual counselling group sessions by cardiac rehabilitation staff to patients during phase III cardiac rehabilitation was identified as the target behaviour. Education, enablement, modelling, persuasion and
...] Examination Guidelines for Implementing the First Inventor To File Provisions of the Leahy-Smith America... concerning the first inventor to file provisions of the Leahy-Smith America Invents Act (AIA). The AIA amends... Inventor To File Provisions of the Leahy-Smith America Invents Act I. Overview of the Changes to 35 U.S.C...
Nuwagaba-Biribonwoha, Harriet; Wang, Chunhui; Kilama, Bonita; Jowhar, Farhat K; Antelman, Gretchen; Panya, Milembe F; Abrams, Elaine J
Introduction Paediatric antiretroviral therapy (ART) guidelines have been updated several times in recent years. We assessed implementation of ART guidelines among under-five children to inform the transition to universal paediatric ART in Tanzania. Methods We conducted a retrospective cohort analysis of infants (0 to 11 months) and children (12 to 59 months) enrolled between 2010 and 2012 using routinely collected data. Infants and children were initiated on ART according to the 2008 World Health Organization (WHO) recommendations/2009 Tanzania guidelines (universal ART for infants). Cumulative ART initiation incidence and correlates of ART initiation were examined using competing risk methods accounting for attrition (death or loss to follow-up). Kaplan-Meier methods and Cox regression models were used to examine attrition on ART and its correlates. Results A total of 1679 children were enrolled at 69 clinics: 469 (28%) infants and 1210 (74%) children. Infant cumulative ART initiation incidence was 59.6, 71.3 and 78.0% at one, three and six months of follow-up. Infants were more likely to start ART if enrolled in 2012 [adjusted sub-hazard ratio (AsHR)=2.2, 95% confidence interval (CI): 1.7 to 2.8] or 2011 (AsHR=1.8, 95% CI: 1.4 to 2.3) compared to 2010; they were more likely to start ART from prevention of mother-to-child HIV transmission (AsHR=1.6, 95% CI: 1.3 to 2.1) and inpatient wards (AsHR=1.5, 95% CI: 1.2 to 2.0) versus being enrolled from voluntary counselling and testing centres. Attrition at 12 months on ART was 33.9% and was more likely among infants with WHO Stage 4 [adjusted hazard ratio (AHR)=3.1. 95% CI: 1.8 to 5.2] and severe malnutrition (AHR=1.4, 95% CI: 1.0 to 1.9). Among 599 children eligible for ART at enrolment, cumulative ART initiation incidence was 51.8, 68.6 and 76.1% at one, three, and six months. Children were more likely to start ART if enrolled in 2012 (AsHR=1.8, 95% CI: 1.4 to 2.3) or 2011 (AsHR=1.5, 95% CI: 1.2 to 1.8) compared to
Rudan, Igor; Gibson, Jennifer L.; Ameratunga, Shanthi; El Arifeen, Shams; Bhutta, Zulfiqar A.; Black, Maureen; Black, Robert E.; Brown, Kenneth H.; Campbell, Harry; Carneiro, Ilona; Chan, Kit Yee; Chandramohan, Daniel; Chopra, Mickey; Cousens, Simon; Darmstadt, Gary L.; Gardner, Julie Meeks; Hess, Sonja Y.; Hyder, Adnan A.; Kapiriri, Lydia; Kosek, Margaret; Lanata, Claudio F.; Lansang, Mary Ann; Lawn, Joy; Tomlinson, Mark; Tsai, Alexander C.; Webster, Jayne
This article provides detailed guidelines for the implementation of systematic method for setting priorities in health research investments that was recently developed by Child Health and Nutrition Research Initiative (CHNRI). The target audience for the proposed method are international agencies, large research funding donors, and national governments and policy-makers. The process has the following steps: (i) selecting the managers of the process; (ii) specifying the context and risk management preferences; (iii) discussing criteria for setting health research priorities; (iv) choosing a limited set of the most useful and important criteria; (v) developing means to assess the likelihood that proposed health research options will satisfy the selected criteria; (vi) systematic listing of a large number of proposed health research options; (vii) pre-scoring check of all competing health research options; (viii) scoring of health research options using the chosen set of criteria; (ix) calculating intermediate scores for each health research option; (x) obtaining further input from the stakeholders; (xi) adjusting intermediate scores taking into account the values of stakeholders; (xii) calculating overall priority scores and assigning ranks; (xiii) performing an analysis of agreement between the scorers; (xiv) linking computed research priority scores with investment decisions; (xv) feedback and revision. The CHNRI method is a flexible process that enables prioritizing health research investments at any level: institutional, regional, national, international, or global. PMID:19090596
Tello-Bernabé, Eugenia; Sanz-Cuesta, Teresa; del Cura-González, Isabel; de Santiago-Hernando, María L; Jurado-Sueiro, Montserrat; Fernández-Girón, Mercedes; García-de Blas, Francisca; Pensado-Freire, Higinio; Góngora-Maldonado, Francisco; de la Puente-Chamorro, María J; Rodríguez-Pasamontes, Carmen; Martín-Iglesias, Susana
Anxiety is a common mental health problem seen in primary care. However, its management in clinical practice varies greatly. Clinical practice guidelines (CPGs) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit. However, uptake and adherence to their recommendations can be low. This study involves a community based on cluster randomized trial in primary healthcare centres in the Madrid Region (Spain). The project aims to determine whether the use of implementation strategy (including training session, information, opinion leader, reminders, audit, and feed-back) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion. The number of patients required is 296 (148 in each arm), all older than 18 years and diagnosed with generalized anxiety disorder, panic disorder, and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). They are chosen by consecutive sampling. The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months. Secondary outcome variables include quality of life (EuroQol 5D), and degree of compliance with the CPG recommendations on treatment, information, and referrals to mental health services. Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care. Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive. ISRCTN: ISRCTN83365316.
Full Text Available Abstract Background Anxiety is a common mental health problem seen in primary care. However, its management in clinical practice varies greatly. Clinical practice guidelines (CPGs have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit. However, uptake and adherence to their recommendations can be low. Method/design This study involves a community based on cluster randomized trial in primary healthcare centres in the Madrid Region (Spain. The project aims to determine whether the use of implementation strategy (including training session, information, opinion leader, reminders, audit, and feed-back of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion. The number of patients required is 296 (148 in each arm, all older than 18 years and diagnosed with generalized anxiety disorder, panic disorder, and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV. They are chosen by consecutive sampling. The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months. Secondary outcome variables include quality of life (EuroQol 5D, and degree of compliance with the CPG recommendations on treatment, information, and referrals to mental health services. Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. Discussion There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care. Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care
Goossens, Eva; Fernandes, Susan M; Landzberg, Michael J; Moons, Philip
Although different guidelines on adult congenital heart disease (ACHD) care advocate for lifetime cardiac follow-up, a critical appraisal of the guideline implementation is lacking. We investigated the implementation of the American College of Cardiology/American Heart Association 2008 guidelines for ACHD follow-up by investigating the type of health care professional, care setting, and frequency of outpatient visits in young adults with CHD. Furthermore, correlates for care in line with the recommendations or untraceability were investigated. A cross-sectional observational study was conducted, including 306 patients with CHD who had a documented outpatient visit at pediatric cardiology before age 18 years. In all, 210 patients (68.6%) were in cardiac follow-up; 20 (6.5%) withdrew from follow-up and 76 (24.9%) were untraceable. Overall, 198 patients were followed up in tertiary care, 1/4 (n = 52) of which were seen at a formalized ACHD care program and 3/4 (n = 146) remained at pediatric cardiology. Of those followed in formalized ACHD and pediatric cardiology care, the recommended frequency was implemented in 94.2% and 89%, respectively (p = 0.412). No predictors for the implementation of the guidelines were identified. Risk factors for becoming untraceable were none or lower number of heart surgeries, health insurance issues, and nonwhite ethnicity. In conclusion, a significant number of adults continue to be cared for by pediatric cardiologists, indicating that transfer to adult-oriented care was not standard practice. Frequency of follow-up for most patients was in line with the ACC/AHA 2008 guidelines. A considerable proportion of young adults were untraceable in the system, which makes them vulnerable for discontinuation of care. Copyright © 2015 Elsevier Inc. All rights reserved.
Runeson, Per; Rainer, Austen; Regnell, Bjorn
Based on their own experiences of in-depth case studies of software projects in international corporations, in this book the authors present detailed practical guidelines on the preparation, conduct, design and reporting of case studies of software engineering. This is the first software engineering specific book on the case study research method.
Carrera, Pricivel M; Lambooij, Mattijs S
Out-of-office blood pressure monitoring is promoted by various clinical guidelines toward properly diagnosing and effectively managing hypertension and engaging the patient in their care process. In the Netherlands, however, the Dutch cardiovascular risk management (CVRM) guidelines do not explicitly prescribe 24-hour ambulatory blood pressure measurement (ABPM) and home BP measurement (HBPM). The aim of this descriptive study was to develop an understanding of patients' and physicians' acceptance and use of out-of-office BP monitoring in the Netherlands given the CVRM recommendations.Three small focus group discussions (FGDs) with patients and 1 FGD with physicians were conducted to explore the mechanisms behind the acceptance and use of out-of-office BP monitoring and reveal real-world challenges that limit the implementation of out-of-office BP monitoring methods. To facilitate the FGDs, an analytical framework based on the technology acceptance model (TAM), the theory of planned behavior and the model of personal computing utilization was developed to guide the FGDs and analysis of the transcriptions of each FGD.ABPM was the out-of-office BP monitoring method prescribed by physicians and used by patients. HBPM was not offered to patients even with patients' feedback of poor tolerance of ABPM. Even as there was little awareness about HBPM among patients, there were a few patients who owned and used sphygmomanometers. Patients professed and seemed to exhibit self-efficacy, whereas physicians had reservations about (all of their) patients' self-efficacy in properly using ABPM. Since negative experience with ABPM impacted patients' acceptance of ABPM, the interaction of factors that determined acceptance and use was found to be dynamic among patients but not for physicians.In reference to the CVRM guidelines, physicians implemented out-of-office BP monitoring but showed a strong preference for ABPM even where there is poor tolerance of the method. We found that
Babiker, Amir; Amer, Yasser S; Osman, Mohamed E; Al-Eyadhy, Ayman; Fatani, Solafa; Mohamed, Sarar; Alnemri, Abdulrahman; Titi, Maher A; Shaikh, Farheen; Alswat, Khalid A; Wahabi, Hayfaa A; Al-Ansary, Lubna A
Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI. This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase. The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan. In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions. © 2017 John Wiley & Sons, Ltd.
Lilley, Margaret; Hume, Stacey; Karpoff, Nina; Maire, Georges; Taylor, Sherry; Tomaszewski, Robert; Yoshimoto, Maisa; Christian, Susan
The Society of Obstetricians and Gynecologists of Canada and the Canadian College of Medical Genetics published guidelines, in 2011, recommending replacement of karyotype with quantitative fluorescent polymerase chain reaction when prenatal testing is performed because of an increased risk of a common aneuploidy. This study's objective is to perform a cost analysis following the implementation of quantitative fluorescent polymerase chain reaction as a stand-alone test. A total of 658 samples were received between 1 April 2014 and 31 August 2015: 576 amniocentesis samples and 82 chorionic villi sampling. A chromosome abnormality was identified in 14% (93/658) of the prenatal samples tested. The implementation of the 2011 Society of Obstetricians and Gynecologists of Canada and the Canadian College of Medical Genetics guidelines in Edmonton and Northern Alberta resulted in a cost savings of $46 295.80. The replacement of karyotype with chromosomal microarray for some indications would be associated with additional costs. The implementation of new test methods may provide cost savings or added costs. Cost analysis is important to consider during the implementation of new guidelines or technologies. © 2017 John Wiley & Sons, Ltd. © 2017 John Wiley & Sons, Ltd.
de Beurs, Derek P; de Groot, Marieke H; de Keijser, Jos; Mokkenstorm, Jan; van Duijn, Erik; de Winter, Remco F P; Kerkhof, Ad J F M
Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline. 45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments. Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found. The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study. Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients. Netherlands Trial Register (NTR3092 www.trialregister.nl). Copyright © 2015 The
Maria Fernanda Rios Cavalcanti
Full Text Available The aim of the present article is to tackle the controversy of establishing guidelines for qualitative research in Organization and Management Theory (OMT and to present a summary of suggestions on how to conduct good qualitative research given by methodologists on top-tier international publications. In order to do so, the article discusses: general guidelines for qualitative research; how to achieve coherence and transparency in a qualitative empirical study; the meaning and importance of the concept of reflexivity; and, finally how to establish a theoretical contribution and transferability of findings in such context. The work presents a valuable contribution because such guidelines, concepts, and approaches can be adopted by students and researchers when conducting a qualitative research proposal, and by periodic reviewers to evaluate the quality of existing empirical studies.
This Implementation Plan is intended to provide a basis for improvements in the conduct of the Environmental Restoration (ER) Program at Hanford. The Plan is based on the findings of the Schedule Optimization Study (SOS) team which was convened for two weeks in September 1992 at the request of the U.S. Department of Energy (DOE) Richland Operations Office (RL). The need for the study arose out of a schedule dispute regarding the submission of the 1100-EM-1 Operable Unit (OU) Remedial Investigation/Feasibility Study (RI/FS) Work Plan. The SOS team was comprised of independent professionals from other federal agencies and the private sector experienced in environmental restoration within the federal system. The objective of the team was to examine reasons for the lengthy RI/FS process and recommend ways to expedite it. The SOS team issued their Final Report in December 1992. The report found the most serious impediments to cleanup relate to a series of management and policy issues which are within the control of the three parties managing and monitoring Hanford -- the DOE, U.S. Environmental Protection Agency (EPA), and the State of Washington Department of Ecology (Ecology). The SOS Report identified the following eight cross-cutting issues as the root of major impediments to the Hanford Site cleanup. Each of these eight issues is quoted from the SOS Report followed by a brief, general description of the proposed approach being developed
... rule updates the Attorney General's interpretative guidelines under the language minority provisions of.... Also, on July 26, 2002, the Assistant Attorney General of the Civil Rights Division sent a letter to... of the then-existing Attorney General's interpretative guidelines, 28 CFR part 55. This rule conforms...
McLeod, Robin S; Aarts, Mary-Anne; Chung, Frances; Eskicioglu, Cagla; Forbes, Shawn S; Conn, Lesley Gotlib; McCluskey, Stuart; McKenzie, Marg; Morningstar, Beverly; Nadler, Ashley; Okrainec, Allan; Pearsall, Emily A; Sawyer, Jason; Siddique, Naveed; Wood, Trevor
Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.
Seward, Kirsty; Wolfenden, Luke; Wiggers, John; Finch, Meghan; Wyse, Rebecca; Oldmeadow, Christopher; Presseau, Justin; Clinton-McHarg, Tara; Yoong, Sze Lin
While there are number of frameworks which focus on supporting the implementation of evidence based approaches, few psychometrically valid measures exist to assess constructs within these frameworks. This study aimed to develop and psychometrically assess a scale measuring each domain of the Theoretical Domains Framework for use in assessing the implementation of dietary guidelines within a non-health care setting (childcare services). A 75 item 14-domain Theoretical Domains Framework Questionnaire (TDFQ) was developed and administered via telephone interview to 202 centre based childcare service cooks who had a role in planning the service menu. Confirmatory factor analysis (CFA) was undertaken to assess the reliability, discriminant validity and goodness of fit of the 14-domain theoretical domain framework measure. For the CFA, five iterative processes of adjustment were undertaken where 14 items were removed, resulting in a final measure consisting of 14 domains and 61 items. For the final measure: the Chi-Square goodness of fit statistic was 3447.19; the Standardized Root Mean Square Residual (SRMR) was 0.070; the Root Mean Square Error of Approximation (RMSEA) was 0.072; and the Comparative Fit Index (CFI) had a value of 0.78. While only one of the three indices support goodness of fit of the measurement model tested, a 14-domain model with 61 items showed good discriminant validity and internally consistent items. Future research should aim to assess the psychometric properties of the developed TDFQ in other community-based settings.
Treatment with glucocorticoids is the leading cause of drug-induced osteoporosis. National Osteoporosis Guideline Group (NOGG) 2017 guidelines advise a case-finding strategy for patients at risk. The aims of the audit were to evaluate the implementation of the NOGG 2017 guidelines for patients receiving long-term glucocorticoid therapy in a suburban general practice, to instigate changes to ensure 90% of patients are investigated and treated appropriately, and to evaluate impact at a 6-mo re-audit. Reporting Analysis and Intelligence Delivering Results (RAIDR) is a health-care intelligence tool accessing primary care clinical data. Using RAIDR, data on relevant osteoporotic risk factors were combined to produce FRAX scores for patients who had been prescribed glucocorticoids 3 or more times in the past 12 months. FRAX data were displayed in a NOGG guidance graph for major osteoporotic fracture probability. Patients were assessed as high, intermediate, or low risk. High- and intermediate-risk patients above the NOGG threshold were recommended to start bisphosphonates; these patients were sent a prescription for alendronate and a letter of explanation. There were no intermediate patients below the NOGG threshold. Low-risk patients were recommended to have lifestyle advice; a leaflet was produced and sent to these patients. Initial results showed that only 25% of patients recommended to be on bisphosphonates were taking them. Steps were taken to educate the general practitioners in the FRAX tool and NOGG guidelines; the chronic obstructive pulmonary disease annual template was amended to aid adherence by alerting the nurse to the number of glucocorticoid courses prescribed, with additional boxes for prescribing alendronate and printing the lifestyle leaflet; and 2-monthly RAIDR searches by the practice pharmacist were started. A re-audit 6 mo later showed improvement to 92%. This audit showed that education, reminders, and simple computer prompts can greatly improve
Marušić, Ana; Gasparyan, Armen Yuri; Kitas, George D
To adequately translate research into practice, research results should be reported in a way that is useful to practicing clinicians and policymakers. Based on evidence from systematic reviews, the implementation of reporting guidelines, such as CONSORT for randomized controlled trials, may improve the quality of research reporting. We assessed the endorsement of reporting guidelines in rheumatology journals. We analyzed guidelines for authors of all (n = 28) journals indexed in the "Rheumatology" Subject Category of the Journal Citation Reports published in 2012. Journal websites were reviewed for information relevant to reporting guidelines. Out of 28 indexed journals, only about a third (n = 10) endorsed 1 or more reporting guidelines, most commonly CONSORT. General editorial policies, such as those from the International Committee of Medical Journal editors (ICMJE), were endorsed by 19 journals (all 10 journals with and 9 out of 18 without reporting guidelines). Two rheumatology journals introduced specific reporting guidelines about economic studies and genetic association studies. The endorsement of reporting guidelines is low in rheumatology journals. To continue to serve their research community, rheumatology journals should provide the platform for the discussion on most relevant reporting guidelines and adopt them as a group, especially those specific for rheumatology research. Coordinated action of journals and other stakeholders in rheumatology research in the promotion of accurate and transparent reporting of health research studies would be an important part of knowledge translation into practice and well-being of rheumatology patients. Copyright © 2013 Elsevier Inc. All rights reserved.
Salinity guidelines for irrigation: Case studies from Water Research Commission projects along the Lower Vaal, Riet, Berg and Breede Rivers. ... It is suggested that a more dynamic approach be used for managing salinity under irrigation at farm level, i.e. the use of models. Amongst others, future research should focus on ...
Fong de Los Santos, Luis E; Evans, Suzanne; Ford, Eric C; Gaiser, James E; Hayden, Sandra E; Huffman, Kristina E; Johnson, Jennifer L; Mechalakos, James G; Stern, Robin L; Terezakis, Stephanie; Thomadsen, Bruce R; Pronovost, Peter J; Fairobent, Lynne A
The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.The following terms are used in the AAPM practice guidelines:Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.
Suman, Arnela; Schaafsma, Frederieke G; Elders, Petra J M; van Tulder, Maurits W; Anema, Johannes R
Low back pain (LBP) is one of the most prevalent and expensive health care problems in industrialised countries. LBP leads to high health care utility and productivity losses; leaving the individual, the employer, and society with substantial costs. To improve the care for LBP patients and reduce the high societal and financial burden of LBP, in 2010 the 'Multidisciplinary care guideline for nonspecific low back pain' was developed in the Netherlands. The current paper describes the design of a study aiming to evaluate the (cost-) effectiveness of a multifaceted strategy to implement this guideline. In a cluster-randomised controlled trial, the (cost-) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination. Using a stepped-wedge approach, participating general practitioners, physiotherapists, and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session. The timing these clusters receive the training is the unit of randomisation. LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aimed at improving beliefs, cognitions, and self-management. The primary outcome measure of this study is patient back beliefs. Secondary outcome measures on patient level include pain, functional status, quality of life, health care utility, and productivity losses. Outcome measures on professional level include knowledge and attitude towards the guideline, and guideline adherence. A process evaluation for the implementation strategy will be performed among the health care providers and the patients. Furthermore, a qualitative subgroup analysis among patients with various ethnic backgrounds will be performed. This study will give insight into the (cost-) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non
Ilesanmi, Rose Ekama; Gillespie, Brigid M; Adejumo, Prisca Olabisi; Chaboyer, Wendy
The 2014 International Pressure Ulcer Prevention (PUP) Clinical Practice Guidelines (CPG) provides the most current evidence based strategies to prevent Pressure Ulcer (PU). The evidence upon which these guidelines have been developed has predominantly been generated from research conducted in developed countries. Some of these guidelines may not be feasible in developing countries due to structural and resource issues; therefore there is a need to adapt these guidelines to the context thus making it culturally acceptable. To present a protocol detailing the tailoring of international PUPCPG into a care bundle for the Nigerian context. Guided by the Knowledge to Action (KTA) framework, a two phased study will be undertaken. In Phase 1, the Delphi technique with stakeholder leaders will be used to review the current PUPCPG, identifying core strategies that are feasible to be adopted in Nigeria. These core strategies will become components of a PUP care bundle. In Phase 2, key stakeholder interviews will be used to identify the barriers, facilitators and potential implementation strategies to promote uptake of the PUP care bundle. A PUP care bundle, with three to eight components is expected to be developed from Phase 1. Implementation strategies to promote adoption of the PUP care bundle into clinical practice in selected Nigerian hospitals, is expected to result from Phase 2. Engagement of key stakeholders and consumers in the project should promote successful implementation and translate into better patient care. Using KTA, a knowledge translation framework, to guide the implementation of PUPCPG will enhance the likelihood of successful adoption in clinical practice. In implementing a PUP care bundle, developing countries face a number of challenges such as the feasibility of its components and the required resources.
Rose Ekama Ilesanmi
Full Text Available Background: The 2014 International Pressure Ulcer Prevention (PUP Clinical Practice Guidelines (CPG provides the most current evidence based strategies to prevent Pressure Ulcer (PU. The evidence upon which these guidelines have been developed has predominantly been generated from research conducted in developed countries. Some of these guidelines may not be feasible in developing countries due to structural and resource issues; therefore there is a need to adapt these guidelines to the context thus making it culturally acceptable. Aim: To present a protocol detailing the tailoring of international PUPCPG into a care bundle for the Nigerian context. Methods: Guided by the Knowledge to Action (KTA framework, a two phased study will be undertaken. In Phase 1, the Delphi technique with stakeholder leaders will be used to review the current PUPCPG, identifying core strategies that are feasible to be adopted in Nigeria. These core strategies will become components of a PUP care bundle. In Phase 2, key stakeholder interviews will be used to identify the barriers, facilitators and potential implementation strategies to promote uptake of the PUP care bundle. Results: A PUP care bundle, with three to eight components is expected to be developed from Phase 1. Implementation strategies to promote adoption of the PUP care bundle into clinical practice in selected Nigerian hospitals, is expected to result from Phase 2. Engagement of key stakeholders and consumers in the project should promote successful implementation and translate into better patient care. Conclusion: Using KTA, a knowledge translation framework, to guide the implementation of PUPCPG will enhance the likelihood of successful adoption in clinical practice. In implementing a PUP care bundle, developing countries face a number of challenges such as the feasibility of its components and the required resources.
Chandra, Prabha S; Doraiswamy, Padmavathy; Padmanabh, Anuroopa; Philip, Mariamma
Several countries have prescribed standard guidelines for media professionals on suicide reporting. However, the implementation of these guidelines has been varied. Suicide rates in South Asia are one of the highest in the world, and it is known that media guidelines for suicide reporting are not followed adequately. However, there are no published reports available from this region. This study aimed at assessing newspaper reports of suicide for quality of reporting based on standard reporting guidelines and to study differences between English and vernacular (Kannada) newspapers in Bangalore, South India. A total of 341 newspaper reports of suicide from 550 newspapers (3 English and 3 Kannada) over 3 months were systematically assessed for compliance with reporting guidelines. Each report was evaluated on 2 domains and 36 parameters. Data were analyzed for frequency of inappropriate reporting and patterns compared between vernacular and English newspapers. In all, 87% of the reports were those of completed suicide. Non-compliant reporting - method of suicide was reported in 89% and 32% of reports were in prominent pages of the newspaper, 95% mentioned gender, 90% reported the name, 80% reported age and suicide location, 75% reported life events related to suicide, 70% reported occupation, 69% had headline explicity on suicide and 61% reported monocausality. Only 16% reported mental disorder related to suicide, and less than 3% included information on suicide prevention and helplines. Vernacular papers showed significantly better compliance in 16 of the 20 areas. However, protective characteristics were better reported in English newspapers. Majority of reports on suicides in newspapers from Bangalore did not comply with standard guidelines of reporting. There is a strong need to evolve local guidelines and mechanisms for ensuring responsible reporting which have important implications in prevention of suicide. © The Author(s) 2013.
... clinical care practices across the Army health system. This report presents the final results of the evaluation that RAND conducted as part of the demonstration for the low back practice guideline, which was conducted in 1999 and 2000...
The aim of this publication is to facilitate the performance of feasibility studies for Electron Beam flue gas cleanup projects by providing guidelines to conduct these studies and compiling information on the state of the art. This document summarizes the contents of a feasibility study; discusses the main items in plant construction, measurement and control systems, radiation safety and building construction; and lists the required economic data for internationally funded projects.
The aim of this publication is to facilitate the performance of feasibility studies for Electron Beam flue gas cleanup projects by providing guidelines to conduct these studies and compiling information on the state of the art. This document summarizes the contents of a feasibility study; discusses the main items in plant construction, measurement and control systems, radiation safety and building construction; and lists the required economic data for internationally funded projects
Lavergne, Valéry; Ouellet, Georges; Bouchard, Josée
A literature review performed by the EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup highlighted deficiencies in the existing literature, especially the reporting of case studies. Although general reporting guidelines exist for case studies, there are none in the specific field...... of extracorporeal treatments in toxicology. Our goal was to construct and propose a checklist that systematically outlines the minimum essential items to be reported in a case study of poisoned patients undergoing extracorporeal treatments. Through a modified two-round Delphi technique, panelists (mostly chosen...... reports containing data on extracorporeal treatments in poisoning published in Medline in 2011 were reviewed during the external validation rounds. Twenty-one panelists (20 from the EXTRIP workgroup and an invited expert on pharmacology reporting guidelines) participated in the modified Delphi technique...
... 7 Agriculture 6 2010-01-01 2010-01-01 false Guidelines. 622.5 Section 622.5 Agriculture... AGRICULTURE WATER RESOURCES WATERSHED PROJECTS General § 622.5 Guidelines. Guidelines for carrying out... Environmental Principles and Guidelines for Water and Related Land Resources Implementation Studies issued by...
James, J; Place, V; Panda, A [Mayo Clinic, Scottsdale, AZ (United States); Edmonson, H [Mayo Clinic College of Medicine, Rochester, MN (United States); Felmlee, J [Mayo Clinic, Rochester, MN (United States); Pooley, R [Mayo Clinic, Jacksonville, FL (United States)
Purpose: Several institutions have developed MRI guidelines for patients with MR-unsafe or MR-conditional pacemakers. Here we highlight the role of a medical physicist in implementing these guidelines for non-pacemaker dependent patients. Guidelines: Implementing these guidelines requires involvement from several medical specialties and a strong collaboration with the site MRI supervisor to develop a structured workflow. A medical physicist is required to be present during the scan to supervise the MR scanning and to maintain a safety checklist that ensures: 1) uninterrupted patient communication with the technologist, 2) continuous patient physiologic monitoring (e.g. blood pressure and electrocardiography) by a trained nurse, 3) redundant patient vitals monitoring (e.g. pulse oximetry) due to the possibility of in vivo electrocardiography reading fluctuations during image acquisition. A radiologist is strongly recommended to be available to review the images before patients are discharged from the scanner. Pacemaker MRI should be restricted to 1.5T field strength. The MRI sequences should be optimized by the physicist with regards to: a) SAR: limited to <1.5 W/Kg for MR-unsafe pacemakers in normal operating mode, b) RF exposure time: <30 min, c) Coils: use T/R coils but not restricted to such, d) Artifacts: further optimization of sequences whenever image quality is compromised due to the pacemaker. In particular, cardiac, breast and left-shoulder MRIs are most susceptible to these artifacts. Possible strategies to lower the SAR include: a) BW reduction, 2) echo-train-length reduction, 3) increase TR, 4) decrease number of averages, 5) decrease flip angle, 6) reduce slices and/or a combination of all the options. Conclusion: A medical physicist in collaboration with the MR supervisor plays an important role in the supervision/implementation of safe MR scanning of pacemaker patients. Developing and establishing a workflow has enabled our institution to scan over
James, J; Place, V; Panda, A; Edmonson, H; Felmlee, J; Pooley, R
Purpose: Several institutions have developed MRI guidelines for patients with MR-unsafe or MR-conditional pacemakers. Here we highlight the role of a medical physicist in implementing these guidelines for non-pacemaker dependent patients. Guidelines: Implementing these guidelines requires involvement from several medical specialties and a strong collaboration with the site MRI supervisor to develop a structured workflow. A medical physicist is required to be present during the scan to supervise the MR scanning and to maintain a safety checklist that ensures: 1) uninterrupted patient communication with the technologist, 2) continuous patient physiologic monitoring (e.g. blood pressure and electrocardiography) by a trained nurse, 3) redundant patient vitals monitoring (e.g. pulse oximetry) due to the possibility of in vivo electrocardiography reading fluctuations during image acquisition. A radiologist is strongly recommended to be available to review the images before patients are discharged from the scanner. Pacemaker MRI should be restricted to 1.5T field strength. The MRI sequences should be optimized by the physicist with regards to: a) SAR: limited to <1.5 W/Kg for MR-unsafe pacemakers in normal operating mode, b) RF exposure time: <30 min, c) Coils: use T/R coils but not restricted to such, d) Artifacts: further optimization of sequences whenever image quality is compromised due to the pacemaker. In particular, cardiac, breast and left-shoulder MRIs are most susceptible to these artifacts. Possible strategies to lower the SAR include: a) BW reduction, 2) echo-train-length reduction, 3) increase TR, 4) decrease number of averages, 5) decrease flip angle, 6) reduce slices and/or a combination of all the options. Conclusion: A medical physicist in collaboration with the MR supervisor plays an important role in the supervision/implementation of safe MR scanning of pacemaker patients. Developing and establishing a workflow has enabled our institution to scan over
Álvarez Lerma, F; Sánchez García, M; Lorente, L; Gordo, F; Añón, J M; Álvarez, J; Palomar, M; García, R; Arias, S; Vázquez-Calatayud, M; Jam, R
"Zero-VAP" is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units (ICU) consisting of a bundle of ventilator-associated pneumonia (VAP) prevention measures. An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, the project is supported by the Spanish Ministry of Health, and participation is voluntary. In addition to guidelines for VAP prevention, the "Zero-VAP" Project incorporates an integral patient safety program and continuous online validation of the application of the bundle. For the latter, VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program "ENVIN-HELICS" database, which provides continuous information about local, regional and national VAP incidence rates. Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation. A total of 35 preventive measures were initially selected. A task force of experts used the Grading of Recommendations, Assessment, Development and Evaluation Working Group methodology to generate a list of 7 basic "mandatory" recommendations (education and training in airway management, strict hand hygiene for airway management, cuff pressure control, oral hygiene with chlorhexidine, semi-recumbent positioning, promoting measures that safely avoid or reduce time on ventilator, and discouraging scheduled changes of ventilator circuits, humidifiers and endotracheal tubes) and 3 additional "highly recommended" measures (selective decontamination of the digestive tract, aspiration of subglottic secretions, and a short course of iv antibiotic). We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project. Compared to conventional guideline documents, the associated safety assurance program, the
Bazarbachi, Ali; Azim, Hamdy A; Alizadeh, Hussain; Aljurf, Mahmoud; Barista, Ibrahim; Chaudhri, Naeem A; Fahed, Zahira; Fahmy, Omar A; Ghavamzadeh, Ardeshir; Khalaf, Mohamed H; Khatib, Sami; Kutoubi, Aghiad; Paydas, Semra; Elayoubi, Hanadi Rafii; Zaatari, Ghazi; Zawam, Hamdy M; Zelenetz, Andrew D
In the Middle East and North Africa (MENA) region, cancer has many epidemiologic and clinical features that are different from those in the rest of the world. Additionally, the region has a relatively young population and large disparities in the availability of resources at diagnostic and treatment levels. A critical need exists for regional guidelines on cancer care, including those for lymphoid malignancies. A panel of lymphoma experts from MENA reviewed the 2009 version of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) on Non-Hodgkin's Lymphoma and Hodgkin Lymphoma and suggested modifications for the region that were discussed with the United States NCCN Lymphoma Panels. This article presents the consensus recommendations.
Rachel E.A. Horak
Full Text Available A number of national reports, including Vision and Change in Undergraduate Biology Education: A Call to Action, have called for drastic changes in how undergraduate biology is taught. To that end, the American Society for Microbiology (ASM developed new Curriculum Guidelines for undergraduate microbiology that outline a comprehensive curriculum for any undergraduate introductory microbiology course or program of study. Designed to foster enduring understanding of core microbiology concepts, the Guidelines work synergistically with backwards course design to focus teaching on student-centered goals and priorities. In order to qualitatively assess how the ASM Curriculum Guidelines are used by educators and learn more about the needs of microbiology educators, the ASM Education Board distributed two surveys to the ASM education community. In this report, we discuss results of these surveys (353 responses. We found that the ASM Curriculum Guidelines are being implemented in many different types of courses at all undergraduate levels. Educators indicated that the ASM Curriculum Guidelines were very helpful when planning courses and assessments. We discuss some specific ways in which the ASM Curriculum Guidelines have been used in undergraduate classrooms. The survey identified some barriers that microbiology educators faced when trying to adopt the ASM Curriculum Guidelines, including lack of time, lack of financial resources, and lack of supporting resources. Given the self-reported challenges to implementing the ASM Curriculum Guidelines in undergraduate classrooms, we identify here some activities related to the ASM Curriculum Guidelines that the ASM Education Board has initiated to assist educators in the implementation process.
Zgierska, Aleksandra E; Vidaver, Regina M; Smith, Paul; Ales, Mary W; Nisbet, Kate; Boss, Deanne; Tuan, Wen-Jan; Hahn, David L
Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project. A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system's "routine rollout" method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention. Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of
Smith Patricia M
Full Text Available Abstract Background This study was a pre-program evaluation of hospital-based nurses' tobacco intervention beliefs, confidence, training, practice, and perceived intervention barriers and facilitators. It was designed to identify relevant information prior to implementing tobacco cessation guidelines across a large northern rural region, home to 1 urban and 12 rural hospitals. Methods This cross-sectional survey was distributed by nurse managers to nurses in the 13 hospitals and returned by nurses (N = 269 via mail to the researchers. Results Nurses were somewhat confident providing cessation interventions, agreed they should educate patients about tobacco, and 94% perceived tobacco counselling as part of their role. Although only 11% had received cessation training, the majority reported intervening, even if seldom--91% asked about tobacco-use, 96% advised quitting, 89% assessed readiness to quit, 88% assisted with quitting, and 61% arranged post-discharge follow-up. Few performed any of these steps frequently, and among those who intervened, the majority spent Conclusions The findings showed nurses' willingness to engage in tobacco interventions. What the majority were doing maps onto the recommended minimum of 1-3 minutes but intervention frequency and follow-up were suboptimal. The rural-urban differences suggest a need for more research to explore the strengths of rural practice which could potentially inform approaches to smoking cessation in urban hospitals.
Hadely, Kathleen A; Power, Emma; O'Halloran, Robyn
Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists' implementation of stroke CPGs. This study aimed to describe speech pathologists' experiences and current use of guidelines, and to identify what factors influence speech pathologists' implementation of stroke CPGs. Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data. 320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline "somewhat useful" or "very useful". Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided. There are many different factors that can influence speech pathologists' implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.
Graham, Tanya; Alderson, Phil; Stokes, Tim
There is international concern that conflicts of interest (COI) may bias clinical guideline development and render it untrustworthy. Guideline COI policies exist with the aim of reducing this bias but it is not known how such policies are interpreted and used by guideline producing organisations. This study sought to determine how conflicts of interest (COIs) are disclosed and managed by a national clinical guideline developer (NICE: the UK National Institute for Health and Care Excellence). Qualitative study using semi-structured telephone interviews with 14 key informants: 8 senior staff of NICE's guideline development centres and 6 chairs of guideline development groups (GDGs). We conducted a thematic analysis. Participants regard the NICE COI policy as comprehensive leading to transparent and independent guidance. The application of the NICE COI policy is, however, not straightforward and clarity could be improved. Disclosure of COI relies on self reporting and guideline developers have to take "on trust" the information they receive, certain types of COI (non-financial) are difficult to categorise and manage and disclosed COI can impact on the ability to recruit clinical experts to GDGs. Participants considered it both disruptive and stressful to exclude members from GDG meetings when required by the COI policy. Nonetheless the impact of this disruption can be minimised with good group chairing skills. We consider that the successful implementation of a COI policy in clinical guideline development requires clear policies and procedures, appropriate training of GDG chairs and an evaluation of how the policy is used in practice.
McGrew, Susan G.; Peters, Brittany R.; Crittendon, Julie A.; Veenstra-VanderWeele, Jeremy
Genetic testing is recommended for patients with ASD; however specific recommendations vary by specialty. American Academy of Pediatrics and American Academy of Neurology guidelines recommend G-banded karyotype and Fragile X DNA. The American College of Medical Genetics recommends Chromosomal Microarray Analysis (CMA). We determined the yield of…
Ochieng, R.M.; Visseren-Hamakers, Ingrid; Arts, B.; Brockhaus, M.; Herold, M.
The UNFCCC requires REDD+ countries wishing to receive results-based payments to measure, report and verify (MRV) REDD+ impacts; and outlines technical guidelines and good governance requirements for MRV. This article examines institutional effectiveness of REDD+ MRV by assessing countries’ progress
Bousquet, Jean; Schünemann, H. J.; Zuberbier, T.; Bachert, C.; Baena-Cagnani, C. E.; Bousquet, P. J.; Brozek, J.; Canonica, G. W.; Casale, T. B.; Demoly, P.; Gerth van Wijk, R.; Ohta, K.; Bateman, E. D.; Calderon, M.; Cruz, A. A.; Dolen, W. K.; Haughney, J.; Lockey, R. F.; Lötvall, J.; O'Byrne, P.; Spranger, O.; Togias, A.; Bonini, S.; Boulet, L. P.; Camargos, P.; Carlsen, K. H.; Chavannes, N. H.; Delgado, L.; Durham, S. R.; Fokkens, W. J.; Fonseca, J.; Haahtela, T.; Kalayci, O.; Kowalski, M. L.; Larenas-Linnemann, D.; Li, J.; Mohammad, Y.; Mullol, J.; Naclerio, R.; O'Hehir, R. E.; Papadopoulos, N.; Passalacqua, G.; Rabe, K. F.; Pawankar, R.; Ryan, D.; Samolinski, B.; Simons, F. E. R.; Valovirta, E.; Yorgancioglu, A.; Yusuf, O. M.; Agache, I.; Aït-Khaled, N.; Annesi-Maesano, I.; Beghe, B.; Ben Kheder, A.; Blaiss, M. S.; Boakye, D. A.; Bouchard, J.; Burney, P. G.; Busse, W. W.; Chan-Yeung, M.; Chen, Y.; Chuchalin, A. G.; Costa, D. J.; Custovic, A.; Dahl, R.; Denburg, J.; Douagui, H.; Emuzyte, R.; Grouse, L.; Humbert, M.; Jackson, C.; Johnston, S. L.; Kaliner, M. A.; Keith, P. K.; Kim, Y. Y.; Klossek, J. M.; Kuna, P.; Le, L. T.; Lemiere, C.; Lipworth, B.; Mahboub, B.; Malo, J. L.; Marshall, G. D.; Mavale-Manuel, S.; Meltzer, E. O.; Morais-Almeida, M.; Motala, C.; Naspitz, C.; Nekam, K.; Niggemann, B.; Nizankowska-Mogilnicka, E.; Okamoto, Y.; Orru, M. P.; Ouedraogo, S.; Palkonen, S.; Popov, T. A.; Price, D.; Rosado-Pinto, J.; Scadding, G. K.; Sooronbaev, T. M.; Stoloff, S. W.; Toskala, E.; van Cauwenberge, P.; Vandenplas, O.; van Weel, C.; Viegi, G.; Virchow, J. C.; Wang, D. Y.; Wickman, M.; Williams, D.; Yawn, B. P.; Zar, H. J.; Zernotti, M.; Zhong, N.
The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive
Magluta, Cynthia; Gomes, Maria A de Sousa Mendes; Wuillaume, Susana M
Clinical guidelines are tools that systematize scientific evidence and help to achieve proper care. Several difficulties are reported regarding the effective use, such as the shortcomings in the level of knowledge and attitudes by the professionals, the service structure and the preferences appointed by patients. An analysis of these difficulties was the objective of this study in the context of government Neonatal Intensive Care Units (NICU) in Brazil. A semi-structured survey was carried out with 53 managers (medical and nursing) of the 15 NICU in a convenient sample of two groups of government units in Brazil. The managers chose their answers from a list of difficulties to implement the guidelines based on the analytical model of Cabana and graded the difficulties found on a 5-point scale with no reference to quality. Respondents have reported several difficulties with the following priority: lack of professionals to provide care, being perceived as more critical within the nursing and physiotherapy crews, minor participation of professionals in the discussion process and inadequate infrastructure. The lack of acquaintance with the guidelines by the professionals has been reported by few of the surveyed. These findings show some common ground to literature pointing the importance of adequate infrastructure. Managers showed a low valuation of both the level of knowledge and the professionals' adhesion to the guidelines. © 2011 Blackwell Publishing Ltd.
Yoon, Jeong Hee; Lee, Jeong Min; Park, Joong Won
Hepatocellular carcinoma (HCC) can be diagnosed based on characteristic findings of arterial-phase enhancement and portal/delayed 'washout' in cirrhotic patients. Several countries and major academic societies have proposed varying specific diagnostic criteria for HCC, largely reflecting the variable HCC prevalence in different regions and ethnic groups, as well as different practice patterns. In 2014, a new version of Korean practice guidelines for management of HCC was released by the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC). According to the KLCSG-NCC Korea practice guidelines, if the typical hallmark of HCC (i.e., hypervascularity in the arterial phase with washout in the portal or 3 min-delayed phases) is identified in a nodule ≥ 1 cm in diameter on either dynamic CT, dynamic MRI, or MRI using hepatocyte-specific contrast agent in high-risk groups, a diagnosis of HCC is established. In addition, the KLCSG-NCC Korea practice guidelines provide criteria to diagnose HCC for subcentimeter hepatic nodules according to imaging findings and tumor marker, which has not been addressed in other guidelines such as Association for the Study of Liver Diseases and European Association for the Study of the Liver. In this review, we briefly review the new HCC diagnostic criteria endorsed by the 2014 KLCSG-NCC Korea practice guidelines, in comparison with other recent guidelines; we furthermore address several remaining issues in noninvasive diagnosis of HCC, including prerequisite of sonographic demonstration of nodules, discrepancy between transitional phase and delayed phase, and implementation of ancillary features for HCC diagnosis
Yoon, Jeong Hee; Lee, Jeong Min [Dept. of Radiology, Seoul National University Hospital, Seoul (Korea, Republic of); Park, Joong Won [Center for Liver Cancer, National Cancer Center, Goyang (Korea, Republic of)
Hepatocellular carcinoma (HCC) can be diagnosed based on characteristic findings of arterial-phase enhancement and portal/delayed 'washout' in cirrhotic patients. Several countries and major academic societies have proposed varying specific diagnostic criteria for HCC, largely reflecting the variable HCC prevalence in different regions and ethnic groups, as well as different practice patterns. In 2014, a new version of Korean practice guidelines for management of HCC was released by the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC). According to the KLCSG-NCC Korea practice guidelines, if the typical hallmark of HCC (i.e., hypervascularity in the arterial phase with washout in the portal or 3 min-delayed phases) is identified in a nodule ≥ 1 cm in diameter on either dynamic CT, dynamic MRI, or MRI using hepatocyte-specific contrast agent in high-risk groups, a diagnosis of HCC is established. In addition, the KLCSG-NCC Korea practice guidelines provide criteria to diagnose HCC for subcentimeter hepatic nodules according to imaging findings and tumor marker, which has not been addressed in other guidelines such as Association for the Study of Liver Diseases and European Association for the Study of the Liver. In this review, we briefly review the new HCC diagnostic criteria endorsed by the 2014 KLCSG-NCC Korea practice guidelines, in comparison with other recent guidelines; we furthermore address several remaining issues in noninvasive diagnosis of HCC, including prerequisite of sonographic demonstration of nodules, discrepancy between transitional phase and delayed phase, and implementation of ancillary features for HCC diagnosis.
Hoelzer, S; Schweiger, R K; Boettcher, H A; Tafazzoli, A G; Dudeck, J
The purpose of guidelines in clinical practice is to improve the effectiveness and efficiency of clinical care. It is known that nationally or internationally produced guidelines which, in particular, do not involve medical processes at the time of consultation, do not take local factors into account, and have no consistent implementation strategy, have limited impact in changing either the behaviour of physicians, or patterns of care. The literature provides evidence for the effectiveness of computerization of CPGs for increasing compliance and improving patient outcomes. Probably the most effective concepts are knowledge-based functions for decision support or monitoring that are integrated in clinical information systems. This approach is mostly restricted by the effort required for development and maintenance of the information systems and the limited number of implemented medical rules. Most of the guidelines are text-based, and are primarily published in medical journals and posted on the internet. However, internet-published guidelines have little impact on the behaviour of physicians. It can be difficult and time-consuming to browse the internet to find (a) the correct guidelines to an existing diagnosis and (b) and adequate recommendation for a specific clinical problem. Our objective is to provide a web-based guideline service that takes as input clinical data on a particular patient and returns as output a customizable set of recommendations regarding diagnosis and treatment. Information in healthcare is to a very large extent transmitted and stored as unstructured or slightly structured text such as discharge letters, reports, forms, etc. The same applies for facilities containing medical information resources for clinical purposes and research such as text books, articles, guidelines, etc. Physicians are used to obtaining information from text-based sources. Since most guidelines are text-based, it would be practical to use a document-based solution
Hedin, Katarina; Strandberg, Eva Lena; Gröndal, Hedvig; Brorsson, Annika; Thulesius, Hans; André, Malin
To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Qualitative content analysis was used to analyse semi-structured interviews. Swedish primary care. A strategic sample of 25 GPs. Perceived management of sore throat patients. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.
Full Text Available Abstract Background Venous Thromboembolism (VTE is a cause of hospital mortality and managing its morbidity is associated with significant expenditure. Uptake of evidenced based guideline recommendations intended to prevent VTE in hospital settings is sub-optimal. This study was conducted to explore clinicians' attitudes and the clinical environment in which they work to understand their reluctance to adopt VTE prophylaxis guidelines. Methods Between February and November 2009, 40 hospital employed doctors from 2 Australian metropolitan hospitals were interviewed in depth. Qualitative data were analysed according to thematic methodology. Results Analysis of interviews revealed that barriers to evidence based practice include i the fragmented system of care delivery where multiple members of teams and multiple teams are responsible for each patient's care, and in the case of VTE, where everyone shares responsibility and no-one in particular is responsible; ii the culture of practice where team practice is tailored to that of the team head, and where medicine is considered an 'art' in which guidelines should be adapted to each patient rather than applied universally. Interviewees recommend clear allocation of responsibility and reminders to counteract VTE risk assessment being overlooked. Conclusions Senior clinicians are the key enablers for practice change. They will need to be convinced that guideline compliance adds value to their patient care. Then with the support of systems in the organisation designed to minimize the effects of care fragmentation, they will drive practice changes in their teams. We believe that evidence based practice is only possible with a coordinated program that addresses individual, cultural and organisational constraints.
Grimshaw Jeremy M
Full Text Available Abstract Background There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain. Methods We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation. Results Fifty-three of 235 studies (22.5% were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42 used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation, diffusion of innovations, information overload and social marketing (academic detailing. Conclusions There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.
Davies, Philippa; Walker, Anne E; Grimshaw, Jeremy M
There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain. We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation). Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing). There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.
Shnier, Adrienne; Lexchin, Joel; Romero, Mirna; Brown, Kevin
Clinical practice guidelines are widely distributed by medical associations and relied upon by physicians for the best available clinical evidence. International findings report that financial conflicts of interest (FCOI) with drug companies may influence drug recommendations and are common among guideline authors. There is no comparable study on exclusively Canadian guidelines; therefore, we provide a case study of authors' FCOI declarations in guidelines from the Canadian Medical Association (CMA) Infobase. We also assess the financial relationships between guideline-affiliated organizations and drug companies. Using a population approach, we extracted first-line drug recommendations and authors' FCOI disclosures in guidelines from the CMA Infobase. We contacted the corresponding authors on guidelines when FCOI disclosures were missing for some or all authors. We also extracted guideline-affiliated organizations and searched each of their websites to determine if they had financial relationships with drug companies. We analyzed 350 authors from 28 guidelines. Authors were named on one, two, or three guidelines, yielding 400 FCOI statements. In 75.0 % of guidelines at least one author, and in 21.4 % of guidelines all authors, disclosed FCOI with drug companies. In 54.0 % of guidelines at least one author, and in 28.6 % of guidelines over half of the authors, disclosed FCOI with manufacturers of drugs that they recommended. Twenty of 48 authors on multiple guidelines reported different FCOI in their disclosures. Eight guidelines identified affiliated organizations with financial relationships with manufacturers of drugs recommended in those guidelines. This is the first study to systematically describe FCOI disclosures by authors of Canadian guidelines and financial relationships between guideline-affiliated organizations and pharmaceutical companies. These financial relationships are common. Because authoritative value is assigned to guidelines distributed by
Singh, Harminder; Leontiadis, Grigorios I; Hookey, Lawrence; Enns, Robert; Bistritz, Lana; Rioux, Louis-Charles; Hope, Louise; Sinclair, Paul
An important mandate of the Canadian Association of Gastroenterology (CAG), as documented in the Association’s governance policies, is to optimize the care of patients with digestive disorders. Clinical practice guidelines are one means of achieving this goal. The benefits of timely, high-quality and evidenced-based recommendations include: Enhancing the professional development of clinical members through education and dissemination of synthesized clinical research;Improving patient care provided by members by providing focus on quality and evidence;Creating legislative environments that favour effective clinical practice;Enhancing the clinical care provided to patients with digestive disease by nongastroenterologists; andIdentifying areas that require further information or research to improve clinical care.The present document provides the foundation required to ensure that clinical practice guidelines produced by the CAG are necessary, appropriate, credible and applicable. These recommendations should be adhered to as closely as possible to obtain CAG endorsement. PMID:25314352
Makris, Susan L.; Raffaele, Kathleen; Allen, Sandra
OBJECTIVE: We conducted a review of the history and performance of developmental neurotoxicity mic (DNT) testing in support of the finalization and implementation of Organisation of Economic Co-operation and Development (OECD) DNT test guideline 426 (TG 426). INFORMATION SOURCES AND ANALYSIS......: In this review we summarize extensive scientific efforts that form the foundation for this testing paradigm, including basic neurotoxicology research, interlaboratory collaborative studies, expert workshops, and validation studies, and we address the relevance, applicability, and use of the DNT study in risk...... and international acceptance of new or updated test methods for hazard characterization. Multiple independent, expert scientific peer reviews affirm these conclusions....
Martin, Seth S; Sperling, Laurence S; Blaha, Michael J; Wilson, Peter W F; Gluckman, Ty J; Blumenthal, Roger S; Stone, Neil J
Successful implementation of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines hinges on a clear understanding of the clinician-patient risk discussion (CPRD). This is a dialogue between the clinician and patient about potential for atherosclerotic cardiovascular disease risk reduction benefits, adverse effects, drug-drug interactions, and patient preferences. Designed especially for primary prevention patients, this process of shared decision making establishes the appropriateness of a statin for a specific patient. CPRD respects the autonomy of an individual striving to make an informed choice aligned with personal values and preferences. Dedicating sufficient time to high-quality CPRD offers an opportunity to strengthen clinician-patient relationships, patient engagement, and medication adherence. We review the guideline-recommended CPRD, the general concept of shared decision making and decision aids, the American College of Cardiology/American Heart Association Risk Estimator application as an implementation tool, and address potential barriers to implementation. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Bolbrinker, J; Zaidi Touis, L; Gohlke, H; Weisser, B; Kreutz, R
In the 2013 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines for the management of arterial hypertension, six lifestyle changes for treatment are recommended for the first time with class I, level of evidence A. We initiated a survey among physicians to explore their awareness and consideration of lifestyle changes in hypertension management. The survey included questions regarding demographics as well as awareness and implementation of the recommended lifestyle changes. It was conducted at two German and two European scientific meetings in 2015. In all, 1064 (37.4% female) physicians participated (806 at the European and 258 at the German meetings). Of the six recommended lifestyle changes, self-reported awareness was highest for regular exercise (85.8%) followed by reduction of weight (66.2%). The least frequently self-reported lifestyle changes were the advice to quit smoking (47.3%) and moderation of alcohol consumption (36.3%). Similar frequencies were observed for the lifestyle changes implemented by physicians in their care of patients. A close correlation between awareness of guideline recommendations and their implementation into clinical management was observed. European physicians place a stronger emphasis on regular exercise and weight reduction than on the other recommended lifestyle changes. Moderation of alcohol consumption is the least emphasized lifestyle change.
Hood, Kristen; Lewis, Brennan; Bowens, Cindy Darnell
Pediatric patients undergoing tracheostomy placement are often medically fragile with multiple comorbidities. The complexity of these patients partnered with the risks of a newly placed tracheostomy necessitates a clear understanding of patient management and clinical competence. At our institution, a quality improvement initiative was formed with a focus on increasing the safety of these patients by developing a postoperative care guideline. Copyright © 2017 Elsevier Inc. All rights reserved.
Kruijf HAM de; Vegter JJ; Caudet G; Kent R; ECO; BIS; Environment Canada
In het kader van het Memorandum of Understanding tussen Environment Canada en het Ministerie van VROM, Directoraat Generaal Milieubeheer, werd een workshop georganiseerd in Bilthoven, van 7-9 maart 1994, over de ontwikkeling van "Environmental Guidelines" Vertegenwoordigers en specialisten van verschillende terreinen uit zowel Canada als Nederland waren aanwezig en namen deel aan de discussies. Een algemene conclusie was dat de uitwisseling van informatie en benaderingen buitengewoo...
Hextan Y. S. Ngan
The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.
Sinnema, H.; Terluin, B.; Wensing, M.; Volker, D.; Franx, G.; van Balkom, A.J.L.M.; de Lange, J.
Background: The uptake of guideline recommendations in general practice can potentially be improved by designing implementation interventions that are tailored to prospectively identify barriers. However, there is insufficient evidence regarding the most effective and efficient approaches to
Sinnema, H.; Terluin, B.; Wensing, M.; Volker, D.; Franx, G.; Balkom, A. van; Lange, J.
BACKGROUND: The uptake of guideline recommendations in general practice can potentially be improved by designing implementation interventions that are tailored to prospectively identify barriers. However, there is insufficient evidence regarding the most effective and efficient approaches to
Grady, Alice; Seward, Kirsty; Finch, Meghan; Fielding, Alison; Stacey, Fiona; Jones, Jannah; Wolfenden, Luke; Yoong, Sze Lin
To identify perceived barriers and enablers to implementation of dietary guidelines reported by early childhood education center cooks, and barriers and enablers associated with greater implementation based on assessment of center menu compliance. Cross-sectional telephone interview. Early childhood education centers, New South Wales, Australia. A total of 202 cooks responsible for menu planning; 70 centers provided a menu for review of compliance with dietary guidelines. Barriers and enablers to dietary guideline implementation were determined using a tool assessing constructs of the Theoretical Domains Framework (TDF). Higher scores (≥6) for each construct indicated enablers to guideline implementation; lower scores (barriers. Multivariable linear regression identified TDF constructs associated with greater guideline implementation. Scores were lowest for reinforcement (mean, 5.85) and goals (mean, 5.89) domains, and highest for beliefs about consequences (mean, 6.51) and social/professional role and identity (mean, 6.50). The skills domain was positively associated with greater implementation of guidelines based on menu review (P = .01). Cooks perceived social/professional role and identity, and beliefs about consequences to be enablers to dietary guideline implementation; however, only the skills domain was associated with greater implementation. There are opportunities to target the incongruence in perceptions vs reality of the barriers and enablers to implementation. Future research could examine the utility of the TDF to identify barriers and enablers to implementation to inform intervention development and for evaluating interventions to examine intervention mechanisms. Copyright © 2017 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.
To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar. Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context. A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline. A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland. Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery. A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes. © 2015 John Wiley & Sons Ltd.
Liaukus, Christine [Building American Research Alliance, Kent, WA (United States)
Five Steps to Implementing the PHA Energy Efficient Unit Turnover Package (ARIES, 2014) is a guide to prepare for the installation of energy efficient measures during a typical public housing authority unit turnover. While a PHA is cleaning, painting and readying a unit for a new resident, there is an opportunity to incorporate energy efficiency measures to further improve the unit's performance. The measures on the list are simple enough to be implemented by in-house maintenance personnel, inexpensive enough to be folded into operating expenses without needing capital budget, and fast enough to implement without substantially changing the number of days between occupancies, a critical factor for organizations where the demand for dwelling units far outweighs the supply. The following guide lays out a five step plan to implement the EE Unit Turnover Package in your PHA, from an initial Self-Assessment through to Package Implementation.
Rosenberg, Stephen N; Shnaiden, Tatiana L; Wegh, Arnold A; Juster, Iver A
Clinical messages alerting physicians to gaps in the care of specific patients have been shown to increase compliance with evidence-based guidelines. This study sought to measure any additional impact on compliance when alerting messages also were sent to patients. For alerts that were generated by computerized clinical rules applied to claims, compliance was determined by subsequent claims evidence (eg, that recommended tests were performed). Compliance was measured in the baseline year and the study year for 4 study group employers (combined membership >100,000) that chose to add patient messaging in the study year, and 28 similar control group employers (combined membership >700,000) that maintained physician messaging but did not add patient messaging. The impact of patient messaging was assessed by comparing changes in compliance from baseline to study year in the 2 groups. Multiple logistic regression was used to control for differences between the groups. Because a given member or physician could receive multiple alerts, generalized estimating equations with clustering by patient and physician were used. Controlling for differences in age, sex, and the severity and types of clinical alerts between the study and control groups, the addition of patient messaging increased compliance by 12.5% (P compliance with the evidence-based guidelines underlying the alerts.
Cavazos, J M; Naik, A D; Woofter, A; Abraham, N S
Despite wide availability of physician guidelines for safer use of nonsteroidal anti-inflammatory drugs (NSAIDs) and widespread use of these drugs in the US, NSAID prescribing guidelines have been only modestly effective. To identify and describe comprehensively barriers to provider adherence to NSAID prescribing guidelines. We conducted interviews with 25 physicians, seeking to identify the major influences explaining physician non-adherence to guidelines. Interviews were standardized and structured probes were used for clarification and detail. All interviews were audio-taped and transcribed. Three independent investigators analysed the transcripts, using the constant-comparative method of qualitative analysis. Our analysis identified six dominant physician barriers explaining non-adherence to established NSAID prescribing guidelines. These included (i) lack of familiarity with guidelines, (ii) perceived limited validity of guidelines, (iii) limited applicability of guidelines among specific patients, (iv) clinical inertia, (v) influences of prior anecdotal experiences and (vi) medical heuristics. A heterogeneous set of influences are barriers to physician adherence to NSAID prescribing guidelines. Suggested measures for improving guideline-concordant prescribing should focus on measures to improve physician education and confidence in guidelines, implementation of physician/pharmacist co-management strategies and expansion of guideline scope.
Major knowledge gaps and system barriers to guideline implementation among European physicians treating patients with atrial fibrillation: a European Society of Cardiology international educational needs assessment.
Heidbuchel, Hein; Dagres, Nikolaos; Antz, Matthias; Kuck, Karl-Heinz; Lazure, Patrice; Murray, Suzanne; Carrera, Céline; Hindricks, Gerhard; Vahanian, Alec
Guideline-adherent treatment is associated with improved prognosis in atrial fibrillation (AF) patients but is insufficiently implemented in clinical practice. The European Society of Cardiology (ESC) performed a multinational educational needs assessment study among cardiologists, general practitioners/family physicians (GPs/FPs), and neurologists in order to evaluate knowledge and skills of physicians and system factors related to AF care delivery. A total of 561 physicians (294 cardiologists, 131 neurologists, and 136 GPs/FPs) from six European countries participated. This mixed-methods study included exploratory semi-structured qualitative interviews (n = 30) and a quantitative survey that included two clinical cases (n = 531). We identified eight key knowledge gaps and system barriers across all domains of AF care. A majority across all specialties reported skills needing improvement to classify AF pathophysiologically, rather than based on duration of episodes, and reported lack of availability of long-term electrocardiogram recording. Skills interpreting the CHA2DS2-VASc and the HAS-BLED scores were reported as needing improvement by the majority of neurologists (52% and 60%, respectively) and GPs/FPs (65% and 74%). Cardiologists calculated the CHA2DS2-VASc and HAS-BLED scores in 94%/70% in a presented case patient, but only 60%/49% of neurologists and 58%/42% of GPs/FPs did. There was much uncertainty on how to deal with anticoagulant therapy in complex patients. There was also a high disparity in using rate or rhythm control strategies, and indications for ablation. Information delivery to patients and communication between different specialties was often considered suboptimal, while national regulations and restrictions often hamper international guideline implementation. We identified major gaps in physicians' knowledge and skills across all domains of AF care, as well as system factors hampering guideline-compliant care implementation and
Machín, Leandro; Aschemann-Witzel, Jessica; Patiño, Angelina; Moratorio, Ximena; Bandeira, Elisa; Curutchet, María Rosa; Martínez, Joseline; Bove, Isabel; Molina, Verónika; Giménez, Ana; Ares, Gastón
An in-depth understanding of the citizen's perception and behavior is needed for the development of targeted public policies and interventions that can successfully encourage people to shift their dietary patterns and contribute to the prevention of non-communicable diseases. The present work aimed to identify barriers and facilitators for the adoption of the new Uruguayan dietary guidelines from a citizen perspective. Twelve semistructured focus groups were conducted with a total of 91 people (81% female, age 18-64 years) from 3 Uruguayan cities. Findings identified several multifaceted barriers, including lack of value given to food, meals and cooking, taste preferences for unhealthy foods, the unsupportive social context in terms of household preferences, customs and social norms, and lack of control of the situation through insufficient food capabilities, time scarcity, and an adverse food market environment. The potential facilitators discussed in the focus groups were mainly related to policies and regulations to discourage consumption of unhealthful products and the provision of more education and information. In addition, respondents acknowledged the need for own actions in terms of seeking greater cooking skills and enjoyment, incorporating changes in their daily routines and promoting a more supportive social environment. Results suggest that supportive actions are needed to support citizen's adoption of the new Uruguayan dietary guidelines.
Winik, Connie L; Bonham, C Elizabeth
Obesity is a rapidly growing health problem reaching epidemic levels around the world (World Health Organization, 2014). According to the World Health Organization, the current incident rate of obesity makes it the leading risk for deaths across the globe. The United States (USA) is amidst in this growing global epidemic. The obesity epidemic is a nondiscriminatory health problem affecting millions of individuals from a variety of backgrounds and social status. One group impacted by this disease is the US military. The health-related consequences of overweight and obesity has increased our military health care expenditures and has a direct impact on our nation's military readiness (Veterans Affairs/Department of Defense, 2014). The purpose of this Doctor of Nursing Practice project was to implement the Veterans Affairs/Department of Defense's Clinical Practice Guideline on Screening and Management of Overweight and Obesity at a military treatment facility in the Midwest. The goal of the project was to reduce the incidence rate of overweight and obese active duty military service members assigned to a military installation in the Midwest. With institutional review board approval, project implementation results were analyzed with descriptive and inferential statistics (paired t- tests). The goal to reduce the incident rate of overweight and obese by 5% was not achieved, but in turn the rate of overweight and obese increased by 1.57% over the 6-mo period. There were decreases in the normal with an increase in the overweight and obesity rate. This inverse outcome was unexpected and concerning. Based on the project's finding, there is a need to address the perceived barriers to maintaining healthy behaviors to plan future activities. An in-depth look at whether there is a knowledge deficit, a perceived lack of self-efficacy, competing life priorities preventing engagement in health promotion behaviors, or some other element influencing the motivation to change would be
Tien, Shiaw-Wen; Hwang, Wen-Tsung; Tsai, Chih-Hung
A risk-based inspection system and a piping inspection guideline model were developed in this study. The research procedure consists of two parts--the building of a risk-based inspection model for piping and the construction of a risk-based piping inspection guideline model. Field visits at the plant were conducted to develop the risk-based inspection and strategic analysis system. A knowledge-based model had been built in accordance with international standards and local government regulations, and the rational unified process was applied for reducing the discrepancy in the development of the models. The models had been designed to analyze damage factors, damage models, and potential damage positions of piping in the petrochemical plants. The purpose of this study was to provide inspection-related personnel with the optimal planning tools for piping inspections, hence, to enable effective predictions of potential piping risks and to enhance the better degree of safety in plant operations that the petrochemical industries can be expected to achieve. A risk analysis was conducted on the piping system of a petrochemical plant. The outcome indicated that most of the risks resulted from a small number of pipelines.
Halsnaes, K.; Callaway, J.M.; Meyer, H.J.
The guideline document establishes a general overview of the main components of climate change mitigation assessment. This includes an outline of key economic concepts, scenario structure, common assumptions, modelling tools and country study assumptions. The guidelines are supported by Handbook Reports that contain more detailed specifications of calculation standards, input assumptions and available tools. The major objectives of the project have been provided a methodology, an implementing framework and a reporting system which countries can follow in meeting their future reporting obligations under the FCCC and for GEF enabling activities. The project builds upon the methodology development and application in the UNEP National Abatement Coasting Studies (UNEP, 1994a). The various elements provide countries with a road map for conducting climate change mitigation studies and submitting national reports as required by the FCCC. (au) 121 refs
Halsnaes, K.; Callaway, J.M.; Meyer, H.J.
The guideline document establishes a general overview of the main components of climate change mitigation assessment. This includes an outline of key economic concepts, scenario structure, common assumptions, modelling tools and country study assumptions. The guidelines are supported by Handbook Reports that contain more detailed specifications of calculation standards, input assumptions and available tools. The major objectives of the project have been provided a methodology, an implementing framework and a reporting system which countries can follow in meeting their future reporting obligations under the FCCC and for GEF enabling activities. The project builds upon the methodology development and application in the UNEP National Abatement Coasting Studies (UNEP, 1994a). The various elements provide countries with a road map for conducting climate change mitigation studies and submitting national reports as required by the FCCC. (au) 121 refs.
Raveis, Victoria H; Conway, Laurie J; Uchida, Mayuko; Pogorzelska-Maziarz, Monika; Larson, Elaine L; Stone, Patricia W
Health-care-associated infections (HAIs) remain a major patient safety problem even as policy and programmatic efforts designed to reduce HAIs have increased. Although information on implementing effective infection control (IC) efforts has steadily grown, knowledge gaps remain regarding the organizational elements that improve bedside practice and accommodate variations in clinical care settings. We conducted in-depth, semistructured interviews in 11 hospitals across the United States with a range of hospital personnel involved in IC (n = 116). We examined the collective nature of IC and the organizational elements that can enable disparate groups to work together to prevent HAIs. Our content analysis of participants' narratives yielded a rich description of the organizational process of implementing adherence to IC. Findings document the dynamic, fluid, interactional, and reactive nature of this process. Three themes emerged: implementing adherence efforts institution-wide, promoting an institutional culture to sustain adherence, and contending with opposition to the IC mandate.
Groot, M. de; Beurs, D.P. de; Keijser, J. de; Kerkhof, A.F.J.M.
An e-learning supported Train-the-Trainer program was developed to implement the Dutch suicide practice guideline inmental health care. Literature on implementation strategies has been restricted to the final reporting of studieswith little opportunity to describe relevant contextual, developmental
Hopewell, Sally; Ravaud, Philippe; Baron, Gabriel; Boutron, Isabelle
To investigate the effect of the CONSORT for Abstracts guidelines, and different editorial policies used by five leading general medical journals to implement the guidelines, on the reporting quality of abstracts of randomised trials. Interrupted time series analysis. We randomly selected up to 60 primary reports of randomised trials per journal per year from five high impact, general medical journals in 2006-09, if indexed in PubMed with an electronic abstract. We excluded reports that did not include an electronic abstract, and any secondary trial publications or economic analyses. We classified journals in three categories: those not mentioning the guidelines in their instructions to authors (JAMA and New England Journal of Medicine), those referring to the guidelines in their instructions to authors but with no specific policy to implement them (BMJ), and those referring to the guidelines in their instructions to authors with an active policy to implement them (Annals of Internal Medicine and Lancet). Two authors extracted data independently using the CONSORT for Abstracts checklist. Mean number of CONSORT items reported in selected abstracts, among nine items reported in fewer than 50% of the abstracts published across the five journals in 2006. We assessed 955 reports of abstracts of randomised trials. Journals with an active policy to enforce the guidelines showed an immediate increase in the level of mean number of items reported (increase of 1.50 items; P=0.0037). At 23 months after publication of the guidelines, the mean number of items reported per abstract for the primary outcome was 5.41 of nine items, a 53% increase compared with the expected level estimated on the basis of pre-intervention trends. The change in level or trend did not increase in journals with no policy to enforce the guidelines (BMJ, JAMA, and New England Journal of Medicine). Active implementation of the CONSORT for Abstracts guidelines by journals can lead to improvements in the
Valentini, V; Glimelius, B; Frascino, V
The past two decades have brought tremendous changes to the practice of radiation oncology and medical oncology. To manage all the complexities related to the new technologies and the new drugs, the radiation and medical oncologists have to enhance their clinical action and professional skill profile. To accomplish this they have to find reliable tools in the quality of their medical practice and in future research activities. Quality assurance (QA) and quality control (QC) for radiation and medical oncologists mean to clarify the different components of the clinical decision, to supervise with proper methodology the required steps needed to accomplish the agreed outcomes and to control them. Quality for radiation and medical oncology means to supervise each clinical and technical component of the whole process to guarantee that all steps together will arrive at the final and best possible outcome. Key components are guidelines, specialization and a multidisciplinary approach. The research of global quality could represent a further complexity, but it is the best tool to give a perspective and a chance to further improvements of our disciplines and to promote better outcome in all cancer patients. Copyright © 2013 Elsevier Ltd. All rights reserved.
Kim, Sang-Tae; Coplen, Tyler B.; Horita, Juske
Carbonate minerals provide a rich source of geochemical information because their δ13C and δ18O values provide information about surface and subsurface Earth processes. However, a significant problem is that the same δ18O value is not reported for the identical carbonate sample when analyzed in different isotope laboratories in spite of the fact that the International Union of Pure and Applied Chemistry (IUPAC) has provided reporting guidelines for two decades. This issue arises because (1) the δ18O measurements are performed on CO2 evolved by reaction of carbonates with phosphoric acid, (2) the acid-liberated CO2 is isotopically fractionated (enriched in 18O) because it contains only two-thirds of the oxygen from the solid carbonate, (3) this oxygen isotopic fractionation factor is a function of mineralogy, temperature, concentration of the phosphoric acid, and δ18O value of water in the phosphoric acid, (4) researchers may use any one of an assortment of oxygen isotopic fractionation factors that have been published for various minerals at various reaction temperatures, and (5) it sometimes is not clear how one should calculate δ18OVPDB values on a scale normalized such that the δ18O value of SLAP reference water is −55.5 ‰ relative to VSMOW reference water.
Ngan, H. Y. S.; Chan, K. K. L.; Cheung, A. N. Y.; Garland, S. M.
This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to health care is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.
Ngan, Hextan Y. S.; Garland, Suzanne M.; Bhatla, Neerja; Pagliusi, Sonia R.; Chan, Karen K. L.; Cheung, Annie N. Y.; Chu, Tang-Yuan; Domingo, Efren J.; Qiao, You Lin; Park, Jong Sup; Tay, Eng Hseon; Supakarapongkul, Wisit
This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed. PMID:21559068
Nguyen, Kim A; de Villiers, Anniza; Fourie, Jean M; Bourne, Lesley T; Hendricks, Michael K
To explore the perceptions of educators from the Western Cape Province about the feasibility of implementing South African food-based dietary guidelines (FBDG) in the national curriculum of primary schools. Combined quantitative and qualitative methods. We report on the quantitative component. Twelve public primary schools of different socio-economic status in three education districts of the Western Cape: Metro Central, Metro East and Cape Winelands. Educators (n 256) participated in the self-completed questionnaire survey. Educators assessed that FBDG were appropriate to South African schoolchildren (94%), could be used as an education tool (97%) and fill gaps in the current curriculum about healthy dietary habits (91%). Besides Life Orientation, FBDG could be taught in other learning areas from grades 3 to 7 (9-13 years old). Important barriers to implementing FBDG in the curriculum were educators' workload (61%), insufficient time (46%), learners' disadvantaged background (43%) and educators' lack of knowledge (33%). Other approaches to teach children about FBDG included linking these to the National School Nutrition Programme (82%), school tuck shops (79%), parent meetings (75%), school nutrition policy (73%) and school assembly (57%). Educators in high-income schools perceived that learners' lifestyle was significantly worse (P school assembly were the best means to teach pupils about FBDG (P school curriculum is seen as important together with optimizing the school physical environment. Key factors required for successful implementation in the curriculum are sufficient educational materials, adequate time allocation and appropriate educator training.
Relling, M V; McDonagh, E M; Chang, T; Caudle, K E; McLeod, H L; Haidar, C E; Klein, T; Luzzatto, L
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is associated with development of acute hemolytic anemia (AHA) induced by a number of drugs. We provide guidance as to which G6PD genotypes are associated with G6PD deficiency in males and females. Rasburicase is contraindicated in G6PD-deficient patients due to the risk of AHA and possibly methemoglobinemia. Unless preemptive genotyping has established a positive diagnosis of G6PD deficiency, quantitative enzyme assay remains the mainstay of screening prior to rasburicase use. The purpose of this article is to help interpret the results of clinical G6PD genotype tests so that they can guide the use of rasburicase. Detailed guidelines on other aspects of the use of rasburicase, including analyses of cost-effectiveness, are beyond the scope of this document. Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines are published and updated periodically on https://www.pharmgkb.org/page/cpic to reflect new developments in the field.
Full Text Available In view of the existing research into the implementation of CLIL in Lithuania, it can be claimed that this wellestablished and globally applied teaching and learning methodology has already had some due appreciation in Lithuanian secondary schools. Nevertheless, there still exist numerous obstacles to the broader and more intensive application of CLIL which is strongly lagging behind in comparison to many other countries in Europe and world-wide. The present study aims at exploring the rich experience in CLIL implementation accumulated by Šiauliai Didždvario gymnasium and examining their multifaceted CLIL module which could be an important source of knowledge and practical know-how for other Lithuanian secondary education institutions planning to start implementing CLIL. The research follows a synthesis of qualitative and quantitative methodology including interviews with CLIL teachers, students and school administration. The study results in a SWOT analysis of implementing CLIL in Lithuania on the basis of CLIL practices at Šiauliai Didždvario gymnasium and sets forth some guidelines for its further advancement.
Mohseni, Aby; Jeffries, Aileen; Fedorchak, Paul [Department of Health, Reactor Safety Section, WA (United States)
Washington State has tested implementation of current ingestion PAGs at several drills and exercises. This testing has shown that protective action decisions cannot be based on computed projected doses (due to many assumptions involved). And so we recommend an alternative, simpler methodology based on the concentration of radionuclides in foods. Simplifying the process helps us to avoid confusing the public and to avoid problems that foster unintended public response. The purpose of the present paper is to describe three such problems, propose tentative solutions, and request federal assistance in arriving at a final resolution.
Mohseni, Aby; Jeffries, Aileen; Fedorchak, Paul
Washington State has tested implementation of current ingestion PAGs at several drills and exercises. This testing has shown that protective action decisions cannot be based on computed projected doses (due to many assumptions involved). And so we recommend an alternative, simpler methodology based on the concentration of radionuclides in foods. Simplifying the process helps us to avoid confusing the public and to avoid problems that foster unintended public response. The purpose of the present paper is to describe three such problems, propose tentative solutions, and request federal assistance in arriving at a final resolution
Lehnert, G.; Philpot, L.
This report documents the initial results of the Nuclear Energy Institute License Renewal Implementation Guideline Task Force over the period August 1994 to July 1995 to develop guidance for complying with technical requirements of 10CFR54. The report also provided a starting point for the development of NEI 95-10, ''Industry Guideline for Implementing the Requirements of 10CCR54-The License Renewal Rule''. Information in this document can be used by utilities to prepare the technical material needed in an application for license renewal (LR) of a nuclear power unit. This guideline provides methods for identifying systems, structures, and components (SSCs) and their intended functions within the scope of license renewal. It identifies structures and components (SCs) requiring aging management review and methods for performing the aging management review. The guideline provides a process for identifying and evaluating time-limited aging analyses
Johnson, JA; Gong, L; Whirl-Carrillo, M; Gage, BF; Scott, SA; Stein, CM; Anderson, JL; Kimmel, SE; Lee, MTM; Pirmohamed, M; Wadelius, M; Klein, TE; Altman, RB
Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the dose required to achieve target anticoagulation. Common genetic variants in the cytochrome P450-2C9 (CYP2C9) and vitamin K–epoxide reductase complex (VKORC1) enzymes, in addition to known nongenetic factors, account for ~50% of warfarin dose variability. The purpose of this article is to assist in the interpretation and use of CYP2C9 and VKORC1 geno-type data for estimating therapeutic warfarin dose to achieve an INR of 2–3, should genotype results be available to the clinician. The Clinical Pharmacogenetics Implementation Consortium (CPIC) of the National Institutes of Health Pharmacogenomics Research Network develops peer-reviewed gene–drug guidelines that are published and updated periodically on http://www.pharmgkb.org based on new developments in the field.1 PMID:21900891
Ebisawa, Katsumi; Hibino, Kenta
The Advanced Safety Examination Guideline for Seismic Design for Nuclear Power Plant (the advanced safety examination guideline) was worked out on September 19, 2006. In this paper, a summary of the method of probability theory in the advanced safety examination guideline and the Seismic PSA Implementation Standards is stated. On utilization of the probability theory for the advanced safety examination guideline, the uncertainty resulting from the process of the decision of the basic design earthquake ground motion (Ss) is stated to be considered using the proper method. The references of the extra probability for evaluation of earthquake hazard and combination of the working load and the earthquake load are stated. Definition, evaluation method and effort to lower the 'residual risks', and relation between the residual risks and the extra probability of Ss are described. A summary of the earthquake-resistant design for nuclear power facilities is explained by the old guideline. (S.Y.)
Dezfuli, Homayoon; Benjamin, Allan; Everett, Christopher; Feather, Martin; Rutledge, Peter; Sen, Dev; Youngblood, Robert
This is the second of two volumes that collectively comprise the NASA System Safety Handbook. Volume 1 (NASASP-210-580) was prepared for the purpose of presenting the overall framework for System Safety and for providing the general concepts needed to implement the framework. Volume 2 provides guidance for implementing these concepts as an integral part of systems engineering and risk management. This guidance addresses the following functional areas: 1.The development of objectives that collectively define adequate safety for a system, and the safety requirements derived from these objectives that are levied on the system. 2.The conduct of system safety activities, performed to meet the safety requirements, with specific emphasis on the conduct of integrated safety analysis (ISA) as a fundamental means by which systems engineering and risk management decisions are risk-informed. 3.The development of a risk-informed safety case (RISC) at major milestone reviews to argue that the systems safety objectives are satisfied (and therefore that the system is adequately safe). 4.The evaluation of the RISC (including supporting evidence) using a defined set of evaluation criteria, to assess the veracity of the claims made therein in order to support risk acceptance decisions.
Grek, Ami; Booth, Sandra; Festic, Emir; Maniaci, Michael; Shirazi, Ehsan; Thompson, Kristine; Starbuck, Angela; Mcree, Chad; Naessens, James M; Moreno Franco, Pablo
The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.
Trautner, Barbara W; Prasad, Pooja; Grigoryan, Larissa; Hysong, Sylvia J; Kramer, Jennifer R; Rajan, Suja; Petersen, Nancy J; Rosen, Tracey; Drekonja, Dimitri M; Graber, Christopher; Patel, Payal; Lichtenberger, Paola; Gauthier, Timothy P; Wiseman, Steve; Jones, Makoto; Sales, Anne; Krein, Sarah; Naik, Aanand Dinkar
Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May's General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes. This project moves from a proof-of-concept effectiveness study to implementation involving
Breen, Sarah-Jane; Rees, Sharon
To identify the barriers to implementation of the Sepsis Six pathway. Research has suggested that compliance with the Sepsis Six pathway remains low. A convenience sample of doctors and nurses from one emergency department, two medical wards and two surgical wards were asked to complete a survey questionnaire. Data from 108 respondents were available for analysis. Doctors and nurses agreed that lack of sepsis recognition during observation rounds and failure to associate sepsis with deranged temperature and blood results acted as barriers to the identification of sepsis. Doctors and nurses agreed that nursing delays and knowledge deficits were the top barriers leading to delay in sepsis treatment. Knowledge deficits, lack of resources and practical issues were barriers identified in this survey. This will inform the educational and process needs of both doctors and nurses in order to improve sepsis care.
Greene, Nathanael J.
The stress rupture specification for Composite Overwrapped Pressure Vessels (COPV) is discussed. The composite shell of the COPV shall be designed to meet the design life considering the time it is under sustained load. A Mechcanical Damage Control Plan (MDCP) shall be created and implemented that assures the COPV will not fail due to mechanical damage due to manufacturing, testing, shipping, installation, or flight. Proven processes and procedures for fabrication and repair shall be used to preclude damage or material degradation during material processing, manufacturing operations, and refurbushment.Selected NDI techniques for the liner and/or boss(es) shall be performed before overwrapping with composite. When visual inspection reveals mechanical damage or defects exceeding manufacturing specification levels (and standard repair procedures), the damaged COPV shall be submitted to a material review board (MRB) for disposition. Every COPV shall be subjected to visual and other non-destructive inspection (NDI), per the inspection plan.
Full Text Available Software engineering education is under constant pressure to provide students with industry-relevant knowledge and skills. Educators must address issues beyond exercises and theories that can be directly rehearsed in small settings. Industry training has similar requirements of relevance as companies seek to keep their workforce up to date with technological advances. Real-life software development often deals with large, software-intensive systems and is influenced by the complex effects of teamwork and distributed software development, which are hard to demonstrate in an educational environment. A way to experience such effects and to increase the relevance of software engineering education is to apply empirical studies in teaching. In this paper, we show how different types of empirical studies can be used for educational purposes in software engineering. We give examples illustrating how to utilize empirical studies, discuss challenges, and derive an initial guideline that supports teachers to include empirical studies in software engineering courses. Furthermore, we give examples that show how empirical studies contribute to high-quality learning outcomes, to student motivation, and to the awareness of the advantages of applying software engineering principles. Having awareness, experience, and understanding of the actions required, students are more likely to apply such principles under real-life constraints in their working life.
Full Text Available There is international concern that conflicts of interest (COI may bias clinical guideline development and render it untrustworthy. Guideline COI policies exist with the aim of reducing this bias but it is not known how such policies are interpreted and used by guideline producing organisations. This study sought to determine how conflicts of interest (COIs are disclosed and managed by a national clinical guideline developer (NICE: the UK National Institute for Health and Care Excellence.Qualitative study using semi-structured telephone interviews with 14 key informants: 8 senior staff of NICE's guideline development centres and 6 chairs of guideline development groups (GDGs. We conducted a thematic analysis.Participants regard the NICE COI policy as comprehensive leading to transparent and independent guidance. The application of the NICE COI policy is, however, not straightforward and clarity could be improved. Disclosure of COI relies on self reporting and guideline developers have to take "on trust" the information they receive, certain types of COI (non-financial are difficult to categorise and manage and disclosed COI can impact on the ability to recruit clinical experts to GDGs. Participants considered it both disruptive and stressful to exclude members from GDG meetings when required by the COI policy. Nonetheless the impact of this disruption can be minimised with good group chairing skills.We consider that the successful implementation of a COI policy in clinical guideline development requires clear policies and procedures, appropriate training of GDG chairs and an evaluation of how the policy is used in practice.
Koo, Hwang Duk; Cho, Woo Sung; Lee, Bong Jae
Ο The main purpose of administrative report of an organization is to deliver a critical mind about surrounding circumstance and rational alternatives to a final decision maker Ο An established report system with unified formality and systematic concept playes critical role to make right decision and efficient review about pending issues Ο By understanding current situation of report system using in KAERI and analysing examples of other organization, we established specific administrative report writing guideline for KAERI Ο We expect efficient communication and increasing productivity from the guideline by establishing and diffusing administrative report common writing guideline reflecting longstanding administrative experience and know-how of a specialized committeeman of KAERI.
Koo, Hwang Duk; Cho, Woo Sung; Lee, Bong Jae
Ο The main purpose of administrative report of an organization is to deliver a critical mind about surrounding circumstance and rational alternatives to a final decision maker Ο An established report system with unified formality and systematic concept playes critical role to make right decision and efficient review about pending issues Ο By understanding current situation of report system using in KAERI and analysing examples of other organization, we established specific administrative report writing guideline for KAERI Ο We expect efficient communication and increasing productivity from the guideline by establishing and diffusing administrative report common writing guideline reflecting longstanding administrative experience and know-how of a specialized committeeman of KAERI
Full Text Available AIM: The objective of this study was to describe the French practice of hypothermia treatment (HT in full-term newborns with hypoxic-ischemic encephalopathy (HIE and to analyze the deviations from the guidelines of the French Society of Neonatology. MATERIALS AND METHODS: From May 2010 to March 2012 we recorded all cases of HIE treated by HT in a French national database. The population was divided into three groups, "optimal HT" (OHT, "late HT" (LHT and "non-indicated" HT (NIHT, according to the guidelines. RESULTS: Of the 311 newborns registered in the database and having HT, 65% were classified in the OHT group, 22% and 13% in the LHT and NIHT groups respectively. The severity of asphyxia and HIE were comparable between newborns with OHT and LHT, apart from EEG. HT was initiated at a mean time of 12 hours of life in the LHT group. An acute obstetrical event was more likely to be identified among newborns with LHT (46%, compared to OHT (34% and NIHT (22%. There was a gradation in the rate of complications from the NIHT group (29% to the LHT (38% group and the OHT group (52%. Despite an insignificant difference in the rates of death or abnormal neurological examination at discharge, nearly 60% of newborns in the OHT group had an MRI showing abnormalities, compared to 44% and 49% in the LHT and NIHT groups respectively. CONCLUSION: The conduct of the HT for HIE newborns is not consistent with French guidelines for 35% of newborns, 22% being explained by an excessive delay in the start of HT, 13% by the lack of adherence to the clinical indications. This first report illustrates the difficulties in implementing guidelines for HT and should argue for an optimization of perinatal care for HIE.
Brooks, Steven C; Morrison, Laurie J
The 2005 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations document represents the most extensive and rigorous systematic review of the resuscitation literature to date and included evidence-based recommendations for post-resuscitation care. A new recommendation for the induction of mild therapeutic hypothermia for comatose cardiac arrest survivors was included in this document. Accordingly, constituent national member associations of ILCOR, including the American Heart Association, incorporated the recommendation for therapeutic hypothermia into their respective guidelines. Despite these endorsements there is a concern that therapeutic hypothermia is not being used in practice. Data from a number of surveys in Europe and the United States suggest that rates of use among physicians may be as low as 30-40%. Despite the cost and effort associated with the production of these guidelines and the potential impact on patient care, current efforts in implementing the guideline have not achieved widespread success. This commentary explores the issue of underutilization of the American Heart Association guidelines for therapeutic hypothermia and looks to the knowledge translation literature to inform a new approach to implementation. We will review the underlying phenomenon of research implementation into practice, specific barriers to guideline implementation and interventions that may improve therapeutic hypothermia uptake.
Mäkinen, Tatu J; Aro, Hannu T; Bragdon, Charles; Malchau, Henrik
Background and purpose Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines. Methods We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met. Results 153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000–2005) and 92 after the guidelines were introduced (2006–2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels. Interpretation The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies. PMID:24954489
Madanat, Rami; Mäkinen, Tatu J; Aro, Hannu T; Bragdon, Charles; Malchau, Henrik
Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines. We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met. 153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000-2005) and 92 after the guidelines were introduced (2006-2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels. The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies.
Álvarez-Del Arco, Débora; Monge, Susana; Rivero-Montesdeoca, Yaiza; Burns, Fiona; Noori, Teymur; Del Amo, Julia
Immigrant populations, especially those from endemic countries, living in the European Union (EU) suffer a disproportionate burden of HIV, delayed diagnosis and poorer access to antiretroviral treatment. While International Organisations are developing recommendations aimed at increasing the uptake of HIV testing, the feasibility and real outcomes of these measures remain unexplored. The aim of this review was, firstly to identify the recommendations of the main International Organisations (IO) on HIV testing in immigrants. Secondly, to describe the challenges for implementing and expanding HIV testing and counselling interventions targeting immigrants by interviewing key informants. The importance of HIV testing in immigrants is discussed, along with the appropriateness of universal HIV testing approaches vs most at risk targeted approaches. Also addressed is, pre- and post-HIV test counselling characteristics and community initiatives suitable to reach this population and, finally the legal issues regarding access to treatment for illegal immigrants. Copyright © 2015 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.
Weel Andre NH
Full Text Available Abstract Background Occupational health professionals may play an important role in preventive health promotion activities for employees. However, due to a lack of knowledge and evidence- and practice based methods and strategies, interventions are hardly being implemented by occupational physicians to date. The aim of the Balance@Work project is to develop, evaluate, and implement an occupational health guideline aimed at the prevention of weight gain among employees. Methods Following the guideline development protocol of the Netherlands Society of Occupational Medicine and the Intervention Mapping protocol, the guideline was developed based on literature, interviews with relevant stakeholders, and consensus among an expert group. The guideline consists of an individual and an environmental component. The individual component includes recommendations for occupational physicians on how to promote physical activity and healthy dietary behavior based on principles of motivational interviewing. The environmental component contains an obesogenic environment assessment tool. The guideline is evaluated in a randomised controlled trial among 20 occupational physicians. Occupational physicians in the intervention group apply the guideline to eligible workers during 6 months. Occupational physicians in the control group provide care as usual. Measurements take place at baseline and 6, 12, and 18 months thereafter. Primary outcome measures include waist circumference, daily physical activity and dietary behavior. Secondary outcome measures include sedentary behavior, determinants of behavior change, body weight and body mass index, cardiovascular disease risk profile, and quality of life. Additionally, productivity, absenteeism, and cost-effectiveness are assessed. Discussion Improving workers' daily physical activity and dietary behavior may prevent weight gain and subsequently improve workers' health, increase productivity, and reduce absenteeism
Verweij, Lisanne M; Proper, Karin I; Weel, Andre N H; Hulshof, Carel T J; van Mechelen, Willem
Occupational health professionals may play an important role in preventive health promotion activities for employees. However, due to a lack of knowledge and evidence- and practice based methods and strategies, interventions are hardly being implemented by occupational physicians to date. The aim of the Balance@Work project is to develop, evaluate, and implement an occupational health guideline aimed at the prevention of weight gain among employees. Following the guideline development protocol of the Netherlands Society of Occupational Medicine and the Intervention Mapping protocol, the guideline was developed based on literature, interviews with relevant stakeholders, and consensus among an expert group. The guideline consists of an individual and an environmental component. The individual component includes recommendations for occupational physicians on how to promote physical activity and healthy dietary behavior based on principles of motivational interviewing. The environmental component contains an obesogenic environment assessment tool. The guideline is evaluated in a randomised controlled trial among 20 occupational physicians. Occupational physicians in the intervention group apply the guideline to eligible workers during 6 months. Occupational physicians in the control group provide care as usual. Measurements take place at baseline and 6, 12, and 18 months thereafter. Primary outcome measures include waist circumference, daily physical activity and dietary behavior. Secondary outcome measures include sedentary behavior, determinants of behavior change, body weight and body mass index, cardiovascular disease risk profile, and quality of life. Additionally, productivity, absenteeism, and cost-effectiveness are assessed. Improving workers' daily physical activity and dietary behavior may prevent weight gain and subsequently improve workers' health, increase productivity, and reduce absenteeism. After an effect- and process evaluation the guideline will be
Natural gas reserves in Slovenia are negligible and, therefore, almost all natural gas has to be imported. The natural gas sources are geographically far from Slovenia, and this fact has a great impact first on costs for providing natural gas, and second, on the possibilities to adjust natural gas prices with other alternative and competitive fuels. Countries that are geographically closer to natural gas sources have lower fixed costs in providing natural gas, while in the case of Slovenia fixed costs could exceed half of total costs. Therefore, those countries may have an essentially different market attitude and behaviour. In Slovenia, there are two levels of supplying customers with the natural gas, i.e.: (a) supplies through the Slovenian natural gas pipeline system to industry and distribution companies; (b) supplies through local distribution networks to households, commercial customers and minor industrial customers. With regard to certain differences existing between those two levels, each level has been using a specific system of setting natural gas price as well as a particular tariff system. This paper refers only to supplying the level mentioned under point a. The new tariff system needs to consider first of all the modes of the natural gas use and possibilities of alternative fuels use. On this basis it shall define competitive conditions, convenient for supplying the natural gas to all categories of customers. The system is going to be introduced in several steps so that all necessary and unavoidable changes shall be gradually implemented. A complete introduction of the new, and to the energy market better adjusted tariff system, depends on a simultaneous introduction of fiscal changes. Due to the great dependence of the introduction of the new tariff system on the appropriate fiscal and tax energy regime, the time necessary for a full introduction may vary. We estimate that the tariff system could be fully introduced in about two-year period, once it
Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.
Fife, Terry D; Colebatch, James G; Kerber, Kevin A; Brantberg, Krister; Strupp, Michael; Lee, Hyung; Walker, Mark F; Ashman, Eric; Fletcher, Jeffrey; Callaghan, Brian; Gloss, David S
To systematically review the evidence and make recommendations with regard to diagnostic utility of cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP, respectively). Four questions were asked: Does cVEMP accurately identify superior canal dehiscence syndrome (SCDS)? Does oVEMP accurately identify SCDS? For suspected vestibular symptoms, does cVEMP/oVEMP accurately identify vestibular dysfunction related to the saccule/utricle? For vestibular symptoms, does cVEMP/oVEMP accurately and substantively aid diagnosis of any specific vestibular disorder besides SCDS? The guideline panel identified and classified relevant published studies (January 1980-December 2016) according to the 2004 American Academy of Neurology process. Level C positive: Clinicians may use cVEMP stimulus threshold values to distinguish SCDS from controls (2 Class III studies) (sensitivity 86%-91%, specificity 90%-96%). Corrected cVEMP amplitude may be used to distinguish SCDS from controls (2 Class III studies) (sensitivity 100%, specificity 93%). Clinicians may use oVEMP amplitude to distinguish SCDS from normal controls (3 Class III studies) (sensitivity 77%-100%, specificity 98%-100%). oVEMP threshold may be used to aid in distinguishing SCDS from controls (3 Class III studies) (sensitivity 70%-100%, specificity 77%-100%). Level U: Evidence is insufficient to determine whether cVEMP and oVEMP can accurately identify vestibular function specifically related to the saccule/utricle, or whether cVEMP or oVEMP is useful in diagnosing vestibular neuritis or Ménière disease. Level C negative: It has not been demonstrated that cVEMP substantively aids in diagnosing benign paroxysmal positional vertigo, or that cVEMP or oVEMP aids in diagnosing/managing vestibular migraine. © 2017 American Academy of Neurology.
Koh, Moonsung; Lee, Youngwook; Yoo, Hosik
Among the extended concepts, a remarkable thing is that nuclear security began to be focused on the human factor as well as technical factors (hardware and software system) because most security lapses at nuclear power facilities result from human failings such as low motivation, miscalculation, or malice. Nuclear Security Culture (NSC) is designed to improve the performance of the human factor and to make its interface with security technology and regulations more effective and smooth. There is a need to develop a variety of more efficient tools for achieving sustainable nuclear security culture. We studied for the implementing guide to establish and enhance the nuclear security culture. We have developed the Nuclear Security Culture Implementing Guidelines for licensees in order to enhance nuclear security culture. Licensees have separately established a separate code of conduct on nuclear security culture for their daily business based on such Implementing Guidelines. The Nuclear Security Culture Implementing Guidelines were developed with sufficient consideration of both the IAEA Security Series on nuclear security culture and the Korean circumstances. In all, the Korean government and licensees have timely established and applied the Implementing Guidelines and code of conduct and consequently paved the way for further improvements of the Korean nuclear security regime. The nuclear security culture will facilitate and optimize the human aspects in our nuclear security programs
Koh, Moonsung; Lee, Youngwook; Yoo, Hosik [Korea Institute of Nuclear Nonproliferation and Control, Daejeon (Korea, Republic of)
Among the extended concepts, a remarkable thing is that nuclear security began to be focused on the human factor as well as technical factors (hardware and software system) because most security lapses at nuclear power facilities result from human failings such as low motivation, miscalculation, or malice. Nuclear Security Culture (NSC) is designed to improve the performance of the human factor and to make its interface with security technology and regulations more effective and smooth. There is a need to develop a variety of more efficient tools for achieving sustainable nuclear security culture. We studied for the implementing guide to establish and enhance the nuclear security culture. We have developed the Nuclear Security Culture Implementing Guidelines for licensees in order to enhance nuclear security culture. Licensees have separately established a separate code of conduct on nuclear security culture for their daily business based on such Implementing Guidelines. The Nuclear Security Culture Implementing Guidelines were developed with sufficient consideration of both the IAEA Security Series on nuclear security culture and the Korean circumstances. In all, the Korean government and licensees have timely established and applied the Implementing Guidelines and code of conduct and consequently paved the way for further improvements of the Korean nuclear security regime. The nuclear security culture will facilitate and optimize the human aspects in our nuclear security programs.
Kuunders, Theo J M; Jacobs, Monique A M; Goor, Ien A M van de; Bon-Martens, Marja J H van; Oers, Hans A M van; Paulussen, Theo G W M
Previous evaluation showed insufficient use of a national guideline for integrated local health policy by Regional Health Services (RHS) in the Netherlands. The guideline focuses on five health topics and includes five checklists to support integrated municipal health policies. This study explores the determinants of guideline use by regional Dutch health professionals. A web survey was send to 304 RHS health professionals. The questionnaire was based on a theory- and research-based framework of determinants of public health innovations. Main outcomes were guideline use and completeness of use, defined as the number of health topics and checklists used. Associations between determinants and (completeness of) guideline use were explored by multivariate regression models. The survey was started by 120 professionals (39%). Finally, results from 73 respondents (24%) were eligible for analyses. All 28 Dutch RHS organizations were represented in the final dataset. About half of the respondents (48%) used the guideline. The average score for completeness of use (potential range 1-10) was 2.37 (sd = 1.78; range 1-7). Knowledge, perceived task responsibility and usability were significantly related to guideline use in univariate analyses. Only usability remained significant in the multivariate model on guideline use. Only self-efficacy accounted for significant proportions of variance in completeness of use. The results imply that strategies to improve guideline use by RHSs should primarily target perceived usability. Self-efficacy appeared the primary target for improving completeness of guideline use. Methods for targeting these determinants in RHSs are discussed.
Full Text Available The research aimed to 1 study problems of strategy implementation in basic educational institutions under Khonkaen Primary Educational Service Area Office 4 ; and 2 propose the guidelines for strategy implementation in basic educational institutions under Khonkaen Primary Educational Service Area Office 4. The study was carried out in 2 phases. In phase 1, it focused on the study and analysis of the strategic implementation problems and phase 2 studied the best practice schools. The informants for the interview in phase 1 comprised 6 school administrators and teachers who were involved in strategy implementation from small-sized, medium-sized, and large-sized schools. They were selected by the use of purposive sampling technique. The population in the study of the strategic implementation problems in basic educational institutions in phase 1 consisted of 543 school administrators and teachers who were involved in strategy implementation from 181 schools under Khonkaen Primary Educational Service Area Office 4 in academic year 2014. The study samples were 217 school administrators and teachers who were involved in strategy implementation from small-sized, medium-sized, and large-sized schools under Khonkaen Primary Educational Service Area Office 4. The samples were selected by the use of stratified sampling technique. The informants of the phase 2 study were 6 school administrators and teachers who were involved in strategy implementation from small-sized, medium-sized, and large-sized best practice schools obtained from purposive sampling technique. The research instruments used for data collection consisted of 2 sets of questionnaires. The Set 1 questionnaire was the 5-point Likert scale on the levels of the problems in implementation with item discrimination at 0.60 – 1.00 and reliability of the whole questionnaire at .9359. The questionnaire contained 3 parts with 65 items. The Set 2 questionnaire comprised 2 parts with 10 items regarding
VanDenKerkhof, Elizabeth G; Friedberg, Elaine; Harrison, Margaret B
Hospital-acquired pressure ulcers in the United States were estimated to cost US$2.2 to US$3.6 billion per year in 1999. In the early 1990s clinical practice guidelines for the prevention and treatment of pressure ulcers were introduced. The purpose of this study was to examine the epidemiology of pressure ulcers in acute care in Canada. The current study is based on 12,787 individuals who were inpatients during a 1-day annual census conducted in an acute care facility in Ontario between 1994 and 2008. The prevalence and incidence of pressure ulcer decreased slightly over time while the risk of pressure ulcer increased. The coccyx sacrum (~27%), heel (13%), ankle (~12%), and ischial tubersosity (~10%) were the most common ulcer sites. The implementation of clinical practice guidelines appears to have improved the quality of patient care, as demonstrated by increasing pressure ulcer risk while the prevalence and incidence of pressure ulcers has remained somewhat constant. From a policy perspective the importance of monitoring and tracking the risk and occurrence of this adverse event provides a general indicator of care, considering the many organizational aspects that may ameliorate risk. © 2011 National Association for Healthcare Quality.
These guidelines were produced in response to a perceived need for clear guidance concerning the implementation of the 10-day and 28-day rules regarding radiological radiation protection practices. At the outset it is important to emphasise that, in all cases, the seriousness of the clinical situation must be taken into account as being of paramount importance and an overriding consideration to the guidelines. Radiographs of the chest, skull and extremities may be done at any time, provided that best practices are adhered to. All requests for radiological examinations of female patients, which place the uterus in or near the primary X-ray beam, i.e. irradiation between the diaphragm and pubis, or nuclear medicine examinations which are likely to result in a dose to the unborn child up to 10 mGy, should include the date of the last menstrual period. The prescriber and practitioner or radiographer should ask a patient beyond day 10 of the menstrual cycle whether she might be pregnant. This enquiry and the patient's answer should be recorded in writing. If the answer is no, the examination may proceed. If the answer is yes or uncertain, the examination should not proceed. In cases of medical emergency, the practitioner or the prescriber, if necessary following discussion with the practitioner or radiographer and taking justification into account, may decide to proceed with the examination. The practitioner or prescriber must record this decision in writing and sign it. The 10-day rule is recommended for certain high dose examinations where the dose to the uterus is likely to exceed 10 mGy. These include a small number of diagnostic X-ray and nuclear medicine procedures. (author)
Sada, Pablo Maria
The purpose of this study was to examine selected industrial education departments and programs of the community colleges in the United States, and to draw some beneficial implications for the establishment of the proposed community colleges in Venezuela. The procedure involved a review of the literature, the construction of a questionnaire, and…
Vlemmix, Floortje; Rosman, Ageeth N; Fleuren, Margot A H; Rijnders, Marlies E B; Beuckens, Antje; Haak, Monique C; Akerboom, Bettina M C; Bais, Joke M J; Kuppens, Simone M I; Papatsonis, Dimitri N; Opmeer, Brent C; van der Post, Joris A M; Mol, Ben Willem J; Kok, Marjolein
Breech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling. The ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured. This study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term. Dutch Trial Register (NTR): 1878.
Papatsonis Dimitri N
Full Text Available Abstract Background Breech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV and the Dutch Society for Obstetrics and Gynaecology (NVOG. Implementation of ECV does not exceed 50 to 60% and probably less. We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling. Method/design The ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV. The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured. Discussion This study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term. Trial
Agha, R A; Borrelli, M R; Farwana, R; Kusu-Orkar, T; Millip, M C; Thavayogan, R; Garner, J; Darhouse, N; Orgill, D P
The PROCESS guideline was developed in 2016 through expert Delphi consensus. It aimed to improve the quality of reporting of surgical case series. This study assessed the impact of the introduction of the PROCESS guideline on reporting for surgical case series submitted to three journals. 20 case series published in the International Journal of Surgery Case Reports (IJSCR), the International Journal of Surgery (IJS) or the Annals of Medicine and Surgery (AMS) in September to December 2016, prior to the introduction of the PROCESS guideline (the pre-PROCESS period), were randomly identified and scored against the PROCESS criteria. Two authors independently scored each article a total score out of 29, the 'PROCESS score' (expressed as a percentage). Scores for the two researchers were compared and consensus was reached to achieve a final score set. The process was repeated for the January 2017 to April 2017 issues of the three journals, post PROCESS implementation (the post-PROCESS period). The mean PROCESS score was 80% (range 66-90%) for the pre-PROCESS period and 84% (range 72-95%) for the post-PROCESS period, a 4% relative increase [STATS]. The Cohen's Kappa score between researchers was 0.907 implying very substantial agreement. Implementation of the PROCESS guideline resulted in a 5% improvement in the reporting quality of surgical case series published in three journals. Further research is needed to identify and successfully navigate existing barriers to greater compliance. Authors, reviewers and editors should adhere to the guidelines to boost reporting quality. Journals should develop their policies and guide for authors to incorporate the guideline and mandate compliance. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Brendebach, Boris [Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) gGmbH, Koeln (Germany). Fachgebiet ' ' Stilllegung' '
The implementation of the requirements of the guideline 2014/59/Euratom (radiation protection safety standards) is challenging for a number of EU member states. Several initiatives were introduced to support the member states accomplishing these challenges. In the frame of the initiatives indications were identified with respect to the need of harmonization for the embodiment of the regulations and the need of the recommendations for the implementation of the requirements. The contribution describes several initiatives and demonstrates exemplary the extracted insights.
Fleuren, M.A.H.; Dommelen, P. van; Dunnink, T.
Preventive Child Health Care (PCHC) services are delivered to all children in the Netherlands by approximately 5500 doctors, nurses and doctor's assistants. In 1996, The Dutch Ministry of Health, Welfare and Sports asked for the development of evidence-based PCHC guidelines. Since 1998, twenty-five
Wiener-Ogilvie, Sharon; Huby, Guro; Pinnock, Hilary; Gillies, John; Sheikh, Aziz
Although the BTS-SIGN asthma guideline is one of the most well known and widely respected guidelines in the world, implementation in UK primary care remains patchy. Building on extensive earlier descriptive work, we sought to explore the way teamwork and inter-professional relationships impact on the implementation of the BTS-SIGN guideline on asthma in general practice. Qualitative comparative case study using nine in-depth interviews and 2 focus groups with general practitioners and practice nurses, involved in delivering asthma care. Participants were purposively recruited from practices in a Scottish health board with high and low compliance with the BTS-SIGN asthma guideline. There was a marked difference in the way respondents from practices with high compliance and respondents from practices with low compliance spoke about the value of guidelines and the challenges of implementing them. On both accounts, the former were more positive than the latter and were able to be more specific about the strategies they used to overcome barriers to implementation. We explored the reason for this difference in response and identified practice organisation, centring on delegation of work to nurses, as a factor mediating the practice's level of compliance. Effective delegation was underpinned by organisation of asthma work among practice members who have the appropriate level of skills and knowledge, know and understand each others' work and responsibilities, communicate well among themselves and trust each others' skills. It was the combination of these factors which made for successful delegation and guideline implementation, not any one factor in isolation. In our sample of practices, teamwork and organisation of care within practices appeared to impact on guideline implementation and further larger studies are needed to explore this issue further. Isolated interventions such as measures to improve staff's knowledge or increased clinical resource and time, which are
Bustin, S.A.; Beaulieu, J.F.; Huggett, J.; Jaggi, R.; Kibenge, F.S.; Olsvik, P.A.; Penning, L.C.; Toegel, S.
MIQE précis: Practical implementation of minimum standard guidelines for fluorescence-based quantitative real-time PCR experiments Stephen A Bustin1 , Jean-François Beaulieu2 , Jim Huggett3 , Rolf Jaggi4 , Frederick SB Kibenge5 , Pål A Olsvik6 , Louis C Penning7 and Stefan Toegel8 1 Centre for
Bekkering, G.E.; Hendriks, H.J.M.; Tulder, van M.; Knol, D.L.; Hoeijenbos, M.; Oostendorp, R.A.B.; Bouter, L.M.
OBJECTIVES: To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain. DESIGN: A cluster randomised controlled trial comparing an active strategy with standard dissemination. SETTING: Primary care physiotherapy practices.
Manatos, Maria J.; Rosa, Maria J.; Sarrico, Cláudia S.
This research seeks to explore academics' perceptions of the importance and degree of implementation of the Standards and Guidelines for Quality Assurance in the European Higher Education Area (ESG) for internal quality assurance. It uses empirical evidence from Portugal, gathered via a questionnaire given to all university academics. Results show…
Planning new basic guideline to the radiological risk. Content, radiological criteria and implementation; Nueva direcctriz basica de planificacion ante el riesgo radiologico. Contenido, criterio radiologicos e implantacion
Calvin Cuartero, M.; Vega Riber, R. de la; Martin Calvarro, J. M.
The most important aspects of the Basic Guideline focus on their area of planning, groups of potential radiological emergencies in the type of activity associated with the levels of response planning and responsible organizations, structure and functions for each level, radiological criteria, implementation and maintenance of the effectiveness of the level of response plans abroad.
Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.
Balas, Michele C; Burke, William J; Gannon, David; Cohen, Marlene Z; Colburn, Lois; Bevil, Catherine; Franz, Doug; Olsen, Keith M; Ely, E Wesley; Vasilevskis, Eduard E
other ICU team members. In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
Developed under a contract with the International Council on Archives, these guidelines are designed to emphasize the role of automation techniques in archives and records services, provide an indication of existing computer systems used in different archives services and of specific computer applications at various stages of archives…
Todd, Christopher A; Sanchez, Ana M; Garcia, Ambrosia; Denny, Thomas N; Sarzotti-Kelsoe, Marcella
The EQAPOL contract was awarded to Duke University to develop and manage global proficiency testing programs for flow cytometry-, ELISpot-, and Luminex bead-based assays (cytokine analytes), as well as create a genetically diverse panel of HIV-1 viral cultures to be made available to National Institutes of Health (NIH) researchers. As a part of this contract, EQAPOL was required to operate under Good Clinical Laboratory Practices (GCLP) that are traditionally used for laboratories conducting endpoint assays for human clinical trials. EQAPOL adapted these guidelines to the management of proficiency testing programs while simultaneously incorporating aspects of ISO/IEC 17043 which are specifically designed for external proficiency management. Over the first two years of the contract, the EQAPOL Oversight Laboratories received training, developed standard operating procedures and quality management practices, implemented strict quality control procedures for equipment, reagents, and documentation, and received audits from the EQAPOL Central Quality Assurance Unit. GCLP programs, such as EQAPOL, strengthen a laboratory's ability to perform critical assays and provide quality assessments of future potential vaccines. © 2013.
Bousquet, J; Schunemann, H J; Fonseca, J; Samolinski, B; Bachert, C; Canonica, G W; Casale, T; Cruz, A A; Demoly, P; Hellings, P; Valiulis, A; Wickman, M; Zuberbier, T; Bosnic-Anticevitch, S; Bedbrook, A; Bergmann, K C; Caimmi, D; Dahl, R; Fokkens, W J; Grisle, I; Lodrup Carlsen, K; Mullol, J; Muraro, A; Palkonen, S; Papadopoulos, N; Passalacqua, G; Ryan, D; Valovirta, E; Yorgancioglu, A; Aberer, W; Agache, I; Adachi, M; Akdis, C A; Akdis, M; Annesi-Maesano, I; Ansotegui, I J; Anto, J M; Arnavielhe, S; Arshad, H; Baiardini, I; Baigenzhin, A K; Barbara, C; Bateman, E D; Beghé, B; Bel, E H; Ben Kheder, A; Bennoor, K S; Benson, M; Bewick, M; Bieber, T; Bindslev-Jensen, C; Bjermer, L; Blain, H; Boner, A L; Boulet, L P; Bonini, M; Bonini, S; Bosse, I; Bourret, R; Bousquet, P J; Braido, F; Briggs, A H; Brightling, C E; Brozek, J; Buhl, R; Burney, P G; Bush, A; Caballero-Fonseca, F; Calderon, M A; Camargos, P A M; Camuzat, T; Carlsen, K H; Carr, W; Cepeda Sarabia, A M; Chavannes, N H; Chatzi, L; Chen, Y Z; Chiron, R; Chkhartishvili, E; Chuchalin, A G; Ciprandi, G; Cirule, I; Correia de Sousa, J; Cox, L; Crooks, G; Costa, D J; Custovic, A; Dahlen, S E; Darsow, U; De Carlo, G; De Blay, F; Dedeu, T; Deleanu, D; Denburg, J A; Devillier, P; Didier, A; Dinh-Xuan, A T; Dokic, D; Douagui, H; Dray, G; Dubakiene, R; Durham, S R; Dykewicz, M S; El-Gamal, Y; Emuzyte, R; Fink Wagner, A; Fletcher, M; Fiocchi, A; Forastiere, F; Gamkrelidze, A; Gemicioğlu, B; Gereda, J E; González Diaz, S; Gotua, M; Grouse, L; Guzmán, M A; Haahtela, T; Hellquist-Dahl, B; Heinrich, J; Horak, F; Hourihane, J O 'b; Howarth, P; Humbert, M; Hyland, M E; Ivancevich, J C; Jares, E J; Johnston, S L; Joos, G; Jonquet, O; Jung, K S; Just, J; Kaidashev, I; Kalayci, O; Kalyoncu, A F; Keil, T; Keith, P K; Khaltaev, N; Klimek, L; Koffi N'Goran, B; Kolek, V; Koppelman, G H; Kowalski, M L; Kull, I; Kuna, P; Kvedariene, V; Lambrecht, B; Lau, S; Larenas-Linnemann, D; Laune, D; Le, L T T; Lieberman, P; Lipworth, B; Li, J; Louis, R; Magard, Y; Magnan, A; Mahboub, B; Majer, I; Makela, M J; Manning, P; De Manuel Keenoy, E; Marshall, G D; Masjedi, M R; Maurer, M; Mavale-Manuel, S; Melén, E; Melo-Gomes, E; Meltzer, E O; Merk, H; Miculinic, N; Mihaltan, F; Milenkovic, B; Mohammad, Y; Molimard, M; Momas, I; Montilla-Santana, A; Morais-Almeida, M; Mösges, R; Namazova-Baranova, L; Naclerio, R; Neou, A; Neffen, H; Nekam, K; Niggemann, B; Nyembue, T D; O'Hehir, R E; Ohta, K; Okamoto, Y; Okubo, K; Ouedraogo, S; Paggiaro, P; Pali-Schöll, I; Palmer, S; Panzner, P; Papi, A; Park, H S; Pavord, I; Pawankar, R; Pfaar, O; Picard, R; Pigearias, B; Pin, I; Plavec, D; Pohl, W; Popov, T A; Portejoie, F; Postma, D; Potter, P; Price, D; Rabe, K F; Raciborski, F; Radier Pontal, F; Repka-Ramirez, S; Robalo-Cordeiro, C; Rolland, C; Rosado-Pinto, J; Reitamo, S; Rodenas, F; Roman Rodriguez, M; Romano, A; Rosario, N; Rosenwasser, L; Rottem, M; Sanchez-Borges, M; Scadding, G K; Serrano, E; Schmid-Grendelmeier, P; Sheikh, A; Simons, F E R; Sisul, J C; Skrindo, I; Smit, H A; Solé, D; Sooronbaev, T; Spranger, O; Stelmach, R; Strandberg, T; Sunyer, J; Thijs, C; Todo-Bom, A; Triggiani, M; Valenta, R; Valero, A L; van Hage, M; Vandenplas, O; Vezzani, G; Vichyanond, P; Viegi, G; Wagenmann, M; Walker, S; Wang, D Y; Wahn, U; Williams, D M; Wright, J; Yawn, B P; Yiallouros, P K; Yusuf, O M; Zar, H J; Zernotti, M E; Zhang, L; Zhong, N; Zidarn, M; Mercier, J
Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery system.
VanDevanter, Nancy; Kumar, Pritika; Nguyen, Nam; Nguyen, Linh; Nguyen, Trang; Stillman, Frances; Weiner, Bryan; Shelley, Donna
Services to treat tobacco dependence are not readily available to smokers in low-middle income countries (LMICs) where smoking prevalence remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of two strategies for implementing tobacco use treatment guidelines in 26 community health centers (CHCs) in Viet Nam. Guided by the Consolidated Framework for Implementation Research (CFIR), prior to implementing the trial, we conducted formative research to (1) identify factors that may influence guideline implementation and (2) inform further modifications to the intervention that may be necessary to translate a model of care delivery from a high-income country (HIC) to the local context of a LMIC. We conducted semi-structured qualitative interviews with CHC medical directors, health care providers, and village health workers (VHWs) in eight CHCs (n = 40). Interviews were transcribed verbatim and translated into English. Two qualitative researchers used both deductive (CFIR theory driven) and inductive (open coding) approaches to analysis developed codes and themes relevant to the aims of this study. The interviews explored four out of five CFIR domains (i.e., intervention characteristics, outer setting, inner setting, and individual characteristics) that were relevant to the analysis. Potential facilitators of the intervention included the relative advantage of the intervention compared with current practice (intervention characteristics), awareness of the burden of tobacco use in the population (outer setting), tension for change due to a lack of training and need for skill building and leadership engagement (inner setting), and a strong sense of collective efficacy to provide tobacco cessation services (individual characteristics). Potential barriers included the perception that the intervention was more complex (intervention characteristic) and not necessarily compatible (inner setting) with current workflows and staffing
S. Souza Possa
Full Text Available Objective: The aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. Materials and methods: A âbefore and afterâ study design with historical control was used. The âbeforeâ period included consecutive patients who underwent UAS before guideline implementation (intervention. The âafterâ period included consecutive patients after guideline implementation. Patients in the preâintervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the postâintervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization. Results: There was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the postâintervention period. No patient who adhered totally to the guideline in the postâintervention period developed atelectasis. Individuals in the postâintervention period presented a shorter length of hospital stay (9.2Â Â±Â 4.1 days compared to patients in the preâintervention period (12.1Â Â±Â 8.3 days (pÂ <Â 0.05. Conclusion: The implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period. Resumo: Objetivo: O objetivo deste estudo foi avaliar a eficÃ¡cia da implementaÃ§Ã£o de uma diretriz de fisioterapia para doentes submetidos a cirurgia abdominal superior (UAS na
Kuunders, T.J.M.; Jacobs, M.A.M.; Paulussen, T.G.W.M.; van de Goor, L.A.M.; van Bon, M.J.H.; van Oers, J.A.M.
Background Previous evaluation showed insufficient use of a national guideline for integrated local health policy by Regional Health Services (RHS) in the Netherlands. The guideline focuses on five health topics and includes five checklists to support integrated municipal health policies. This study
van der Krieke, Lian; Bird, Victoria; Leamy, Mary; Bacon, Faye; Dunn, Rebecca; Pesola, Francesca; Janosik, Monika; Le Boutillier, Clair; Williams, Julie; Slade, Mike
Clinical guidelines for the treatment of people experiencing psychosis have existed for over a decade, but implementation of recommended interventions is limited. Identifying influences on implementation may help to reduce this translational gap. The Structured Assessment of Feasibility (SAFE) measure is a standardised assessment of implementation blocks and enablers. The aim of this study was to characterise and compare the implementation blocks and enablers for recommended psychosis interventions. SAFE was used to evaluate and compare three groups of interventions recommended in the 2014 NICE psychosis guideline: pharmacological (43 trials testing 5 interventions), psychosocial (65 trials testing 5 interventions), and recovery (19 trials testing 5 interventions). The 127 trial reports rated with SAFE were supplemented by published intervention manuals, research protocols, trial registrations and design papers. Differences in the number of blocks and enablers across the three interventions were tested statistically, and feasibility profiles were generated. There was no difference between psychosocial and recovery interventions in the number of blocks or enablers to implementation. Pharmacological interventions (a) had fewer blocks than both psychosocial interventions (χ (2)(3) = 133.77, p Feasibility profiles show that pharmacological interventions are relatively easy to implement but can sometimes involve risks. Psychosocial and recovery interventions are relatively complex but tend to be more flexible and more often manualised. SAFE ratings can contribute to tackling the current implementation challenges in mental health services, by providing a reporting guideline structure for researchers to maximise the potential for implementation and by informing prioritisation decisions by clinical guideline developers and service managers.
Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice--results from a cluster-randomized controlled trial of implementation of a clinical practice guideline.
Peters-Klimm, Frank; Müller-Tasch, Thomas; Remppis, Andrew; Szecsenyi, Joachim; Schellberg, Dieter
Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice. Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline. Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03). Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.
Nielsen, Ole Fiil; Mortensen, Niels Henrik
The paper describes a case study dealing with the process of creating and implementing a product platform. The paper espessially deals with the fact that to obtain the benefits of platforms a permanent change in behaviour in product development must be ensured. This change in behaviour requires...... acceptance and approval from the organisation in general and the commitment from management to enforce agreed-upon decisions. The case study itself was performed in the Danish company LEGO Group. The case study had two objectives: To create a technical architecture and align this architecture...
Smith, Paul H.; Benshoff, James M.; Gonzalez, Laura M.
U.S.-based counselor education faculty increasingly are participating in transnational experiences, such as global research and study abroad. The purpose of this study was to develop guidelines for U.S.-based counselor educators when working transnationally. Using Delphi methodology, 69 consensus guidelines were developed from an expert panel.…
Aarnoudse-Moens, C.S.H.; Rijken, M.; Swarte, R.M.; Andriessen, P.; Horst, H.J. van der; Tollenaer, S.M. Mulder-de; Koopman-Esseboom, C.; Laarman, A.R.C.; Steiner, K.; Hoeven, A. van der; Kornelisse, R.F.; Duvekot, J.J.; Weisglas-Kuperus, N.
OBJECTIVE: Since 2010 the guideline 'Guideline for perinatal policy in cases of extreme prematurity' has advised an active policy in infants born at 24 weeks gestation. We investigated how infants born at 24 and 25 weeks gestation in the first year following the implementation of the guideline had
Broom, Jennifer; Broom, Alex; Kirby, Emma; Post, Jeffrey J
Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP. 20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach. Systematic analysis of the participants' account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy. Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.
Dubravcsik, Zsolt; Farkas, Gyula; Hegyi, Péter; Hritz, István; Kelemen, Dezső; Lásztity, Natália; Morvay, Zita; Oláh, Attila; Pap, Ákos; Párniczky, Andrea; Sahin-Tóth, Miklós; Szentkereszti, Zsolt; Szmola, Richárd; Takács, Tamás; Tiszlavicz, László; Szücs, Ákos; Czakó, László
Autoimmune pancreatitis is a rare disease which can even mimic pancreatic tumor, however, unlike the latter, it requires not surgical but conservative management. Correct diagnosis and differential diagnosis of autoimmune pancreatitis and treatment of these patients requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 29 relevant clinical questions in 4 topics were defined (Basics; Diagnosis; Differential diagnostics; Therapy). Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinial questions were accepted with almost total (more than 95%) agreement. The present guideline is the first evidence based autoimmune pancreatitis guideline in Hungary. The guideline may provide very important and helpful data for tuition of autoimmune pancreatitis, for everyday practice and for establishing proper finance. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.
Ethier, Kathleen A.; Ickovics, Jeannette R.; Fernandez, M. Isabel; Wilson, Tracey E.; Royce, Rachel A.; Koenig, Linda J.
OBJECTIVE: The HIV and Pregnancy Study of the Perinatal Guidelines Evaluation Project is a prospective, longitudinal, multisite study established to: (a) assess the implementation of Public Health Service guidelines regarding the prevention of perinatal HIV transmission and (b) evaluate the psychosocial consequences of HIV infection among pregnant women. A distinctive aspect of the study is the use of an HIV-negative comparison group. This article describes the methodology of the study and baseline characteristics of the study sample. Methods and Results. HIV-infected (n = 336) and uninfected (n = 298) pregnant women were enrolled from four geographic areas: Connecticut, North Carolina, Brooklyn, NY, and Miami, FL. The study included three structured face-to-face interviews from late pregnancy to six months postpartum for HIV-infected and uninfected women. Additional self-reports of medication adherence were collected for the HIV-infected participants, and the medical records of infected mothers and their infants were reviewed. Electronic monitoring of medication adherence was conducted for a subset of the infected women. The groups were successfully matched on self-reported characteristics, including HIV-risk behaviors. More than half of the uninfected women reported a high-risk sexual partner. Baseline comparisons indicated that both the HIV-infected and uninfected women had high levels of depressive symptoms, stress, and recent negative life events. CONCLUSIONS: This study provides a unique description of the psychosocial and behavioral characteristics of a population of low-income women. The results of this study suggest that HIV infection is one of many stressors faced by the women in this study. PMID:12356998
Westerheijden, Donald F.; Kohoutek, Jan
The IBAR project studied barriers higher education institutions experienced to implementing the ESG part 1. Our paper reports on the major findings of this project. After sketching our conceptual approach, we conclude that the ESG Part 1 seem to be functioning as a codification of many policies and
Carrera, Percivil Melendez; Lambooij, Mattijs S.
Out-of-office blood pressure monitoring is promoted by various clinical guidelines toward properly diagnosing and effectively managing hypertension and engaging the patient in their care process. In the Netherlands, however, the Dutch cardiovascular risk management (CVRM) guidelines do not
Mulder, F.; Amara, Sliman Abu; Uustal, M.; Pelkmans, L.; Devriendt, N.; Rogulska, M.; Defranceschi, P.
This handbook aims to guide the local/regional governments all over Europe who are involved in implementing clean(er) fuel policies in transport. The general challenge these governments are facing is how local policies on clean(er) fuels and vehicles can be made operational. Hence, how can the step be made from a vision on the strategic policy level, to a vision on the implementation of these policies. A local/regional policy on clean(er) fuels and vehicles is commonly part of the larger category 'sustainable transport policy', which in itself is part of a broader local environmental policy. The encompassing local/regional sustainable mobility policy will in most cases be based on the three well known main policy aims in this area: CO2 reduction; Improving the local air quality; and Improving the security of supply (locally often less stressed). This handbook will focus on the actual implementation of a clean(er) fuels and vehicles policy. It will describe the main challenges and how these can be overcome. It will describe how the market conditions for clean(er) fuels and vehicles can be created by establishing the vital market elements and which process is required to do so. And it will show how local enterprises can be involved and what the role of the local governments in this process can be. In order to identify the local success factors in overcoming the main challenges for implementation, case studies have been carried out in three European cities, namely Stockholm (Sweden), Graz (Austria) and Lille (France). The choice of these cities was based on their successes in implementing clean(er) fuel policies (although they followed different paths) and the fact that they managed to achieve ambitious clean(er) fuel/ clean(er) vehicle targets. These cities may thus be considered as ?good practice examples?. The case studies are based on existing literature, on multiple stakeholders? interviews in all three cities, and on two small surveys. The objectives of this
Kuschner, Ware G; Gruenewald, David A; Clum, Nancy; Beal, Alice; Ezeji-Okoye, Stephen C
Ethical conflicts are commonly encountered in the course of delivering end-of-life care in the ICU. Some ethical concerns have legal dimensions, including concerns about inappropriate hastening of death. Despite these concerns, many ICUs do not have explicit policies and procedures for withdrawal of life-sustaining treatments. We describe a US Office of Inspector General (OIG) investigation of end-of-life care practices in our ICU. The investigation focused on care delivered to four critically ill patients with terminal diseases and an ICU nurse's concern that the patients had been subjected to euthanasia. The OIG investigation also assessed the validity of allegations that patient flow in and out of our ICU was inappropriately influenced by scheduled surgeries and that end-of-life care policies in our ICU were not clear. Although the investigation did not substantiate the allegations of euthanasia or inappropriate ICU patient flow, it did find that the policies that discuss end-of-life care issues were not clear and allowed for wide-ranging interpretations. Acting on the OIG recommendations, we developed a quality improvement initiative addressing end-of-life care in our ICU, intended to enhance communication and understanding about palliative care practices in our ICU, to prevent ethical conflicts surrounding end-of-life care, and to improve patient care. The initiative included the introduction of newly developed ICU comfort care guidelines, a physician order set, and a physician template note. Additionally, we implemented an educational program for ICU staff. Staff feedback regarding the initiative has been highly favorable, and the nurse whose concerns led to the investigation was satisfied not only with the investigation but also the policies and procedures that were subsequently introduced in our ICU.
Allison, R. L.
Costs for airline operational implementation of a NASA-developed approach energy management system (AEMS) concept, as applied to the 727 airplane, were determined. Estimated costs are provided for airplane retrofit and for installation of the required DME ground stations. Operational costs and fuel cost savings are presented in a cost-of-ownership study. The potential return on the equipment investment is evaluated using a net present value method. Scheduled 727 traffic and existing VASI, ILS, and collocated DME ground station facilities are summarized for domestic airports used by 727 operators.
Spitaels, David; Vankrunkelsven, Patrik; Desfosses, Jurgen; Luyten, Frank; Verschueren, Sabine; Van Assche, Dieter; Aertgeerts, Bert; Hermens, Rosella
Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and facilitators in current care were investigated. Eleven patients with knee OA were extensively interviewed using a semistructured script based on quality indicators. Directed content analysis, within the framework of Grol and Wensing, was performed to describe barriers and facilitators in 6 domains: guideline, health care professional, patient, social environment, organization, and financial context. Data were analyzed using NVIVO 10 software. In total, 38 barriers, at all 6 domains, were identified. The most frequently mentioned barriers were in the domains of the patient and the health care professional, namely, patients' disagreement with guidelines recommendations, negative experience with drugs, patients' limited comprehension of the disease process, and poor communication by the health care professional. The patients' disagreement with recommendations is further explained by the following barriers: "insistence on medical imaging," "fear that physiotherapy aggravates pain," and "perception that knee OA is not a priority health issue". Patients also reported 20 facilitators, all of which are listed as opposing barriers. Patients indicate that both personal factors and factors related to health care professionals play an important role in nonadherence. An interview script, based on quality indicators, was a significant aid to structurally formulate barriers and facilitators in the perceived knee OA care. Future guideline implementation strategies should take the identified barriers and facilitators into account. © 2016 John Wiley & Sons, Ltd.
Jensen, Cathrine Elgaard; Jensen, Martin Bach; Riis, Allan
be included in a comparison with a Danish implementation study to establish which strategy procures most value for money. DESIGN: Systematic review. DATA SOURCES: The search was conducted in Embase, PubMed, Cochrane Library, NHS Economic Evaluation Database, Scopus, CINAHL and EconLit. No restrictions were...... made concerning language, year of publication or publication type. The bibliographies of the included studies were searched for any studies not captured in the literature search. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: To be included, a study must be: (1) based on a randomised controlled trial...
Coombs, Maureen A; Davidson, Judy E; Nunnally, Mark E; Wickline, Mary A; Curtis, J Randall
To explore the importance, challenges, and opportunities using qualitative research to enhance development of clinical practice guidelines, using recent guidelines for family-centered care in the ICU as an example. In developing the Society of Critical Care Medicine guidelines for family-centered care in the neonatal ICU, PICU, and adult ICU, we developed an innovative adaptation of the Grading of Recommendations, Assessments, Development and Evaluations approach to explicitly incorporate qualitative research. Using Grading of Recommendations, Assessments, Development and Evaluations and the Council of Medical Specialty Societies principles, we conducted a systematic review of qualitative research to establish family-centered domains and outcomes. Thematic analyses were undertaken on study findings and used to support Population, Intervention, Comparison, Outcome question development. We identified and employed three approaches using qualitative research in these guidelines. First, previously published qualitative research was used to identify important domains for the Population, Intervention, Comparison, Outcome questions. Second, this qualitative research was used to identify and prioritize key outcomes to be evaluated. Finally, we used qualitative methods, member checking with patients and families, to validate the process and outcome of the guideline development. In this, a novel report, we provide direction for standardizing the use of qualitative evidence in future guidelines. Recommendations are made to incorporate qualitative literature review and appraisal, include qualitative methodologists in guideline taskforce teams, and develop training for evaluation of qualitative research into guideline development procedures. Effective methods of involving patients and families as members of guideline development represent opportunities for future work.
Implementation of the 2013 American College of Cardiology/American Heart Association Blood Cholesterol Guideline Including Data From the Improved Reduction of Outcomes: Vytorin Efficacy International Trial
Ziaeian, Boback; Dinkler, John; Watson, Karol
Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in developed countries. The management of blood cholesterol through use of 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitors (statins) in at-risk patients is a pillar of medical therapy for the primary and secondary prevention of cardiovascular disease. The recent 2013 American College of Cardiology/American Heart Association guideline on managing blood cholesterol provides an important framework for the effective implementation of risk-reduction strategies. The guideline identifies four cohorts of patients with proven benefits from statin therapy and streamlines the dosing and monitoring recommendations based on evidence from published, randomized controlled trials. Primary care physicians and cardiologists play key roles in identifying populations at elevated ASCVD risk. In providing a practical management overview of the current blood cholesterol guideline, we facilitate more informed discussions on treatment options between healthcare providers and their patients. PMID:26198559
Min, Yul Ha; Park, Hyeoun-Ae; Chung, Eunja; Lee, Hyunsook
The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
Graham, Richard N J; Baldwin, David R; Callister, Matthew E J; Gleeson, Fergus V
The British Thoracic Society has published new comprehensive guidelines for the management of pulmonary nodules. These guidelines are significantly different from those previously published, as they use two malignancy prediction calculators to better characterize the risk of malignancy. There are recommendations for a higher nodule size threshold for follow-up (≥5 mm or ≥80 mm(3)) and a reduction of the follow-up period to 1 year for solid pulmonary nodules; both of these will reduce the number of follow-up CT scans. PET-CT plays a crucial role in characterization also, with an ordinal scale being recommended for reporting. Radiologists will be the key in implementing these guidelines, and routine use of volumetric image-analysis software will be required to manage patients with pulmonary nodules correctly.