Guideline Adherence Research Papers - Academia.edu (original) (raw)

The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.

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- Social Sciences, Physical Activity, Exercise therapy, Heart Failure
- by Ashish Pathak
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- Health Care, Risk, Medicine, Multidisciplinary
- by Lisa Segre
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- Program Evaluation, Depression, Pregnancy, Program Development

This qualitative study used the grounded theory method to investigate district nurses' experiences of caring for leg ulcers in accordance with clinical guidelines at seven primary health care centres in Stockholm, Sweden. Group interviews were conducted with 30 nurses. The results describe how district nurses strive to stay on track in order to follow clinical guidelines and remain motivated despite prolonged wound treatment and feelings of hopelessness. Three main obstacles to following the guidelines were found. District nurses used compensating strategies so the obstacles would not lead to negative consequences. If the compensating strategies were insufficient, perceived prolonged wound treatment and feelings of hopelessness could result. District nurses then used motivating strategies to overcome these feelings of hopelessness. Sometimes, despite the motivating strategies, treatment in accordance with guidelines could not be achieved. With some patients, district nurses had ...

- by Ingrid Hylander
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- Primary Health Care, Wound Healing, Hope, Qualitative Research
- by Eldar Søreide
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- Evidence Based Medicine, Survival Analysis, Medicine, Emergency Medical Services
- by Anthony Rudd
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- Stroke rehabilitation, Medicine, Stroke, Clinical Medicine

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14 (7%) fixed outlets and 16/70 (23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

- by Victoria Flood
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- Business, Nutrition and Dietetics, Medicine, Commerce

BACKGROUND The compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) in Israel has not been determined. OBJECTIVES To evaluate the compliance of hospital staff with guidelines for the active surveillance of MRSA and assess its impact on the incidence of nosocomial MRSA bacteremia. METHODS We assessed compliance with MRSA surveillance guidelines by assessing adherence to the screening protocol and reviewing medical and nursing charts of patients colonized with MRSA, and observed hand hygiene opportunities among health care workers and colonized patients. Rates of nosocomial MRSA bacteremia and of adherence with hand hygiene among overall hospital staff were obtained from archived data for the period 2001-2010. RESULTS Only 32.4% of eligible patients were screened for MRSA carriage on admission, and 69.9% of MRSA carriers did not receive any eradication treatment. The mean rate of adherence to glove use among nur...

- by Naiel Bisharat
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- Medicine, Israel, Policy making, Infection Control

Oral care is an important feature of nursing; it is known that oropharynx is considered the main reservoir of bacterial colonization, so the removal of oral infection is a major duty of all health care providers, particularly nurses. We performed this study to explore endotracheal tube and oral care practices for mechanically ventilated patients of Jordanian intensive care nurses, and to study Jordanian intensive care nurses' practices during, prior to, and post endotracheal tube and oral care for mechanically ventilated patients. Endotracheal tube and oral care of Jordanian intensive care nurses for mechanically ventilated patients was compared with recommendations for endotracheal tube and oral care of American Association of Critical Care Nurses and guidelines of Centers for Disease Control and Prevention. Non-participant structured observational design was conducted using a 24-item structured observational schedule. The findings show that nurses different in their oral care practices; did not follow American Association of Critical Care Nurses recommendations; and therefore delivered lower-quality oral care than predictable. Important inconsistencies were observed in the nurses' hyperoxygenation, respiratory assessment techniques and infection control practices.

- by Mohammed ALBashtawy
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- Jordan, Observation, INTENSIVE CARE, Oral Hygiene
- by Marcelo Prado
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- Nursing, Brazil, Hand Hygiene, Prospective studies

and hospital performance measures used to ensure quality care. Nurses are often the primary providers of education to patients with HF. This study assessed nurses' knowledge of basic principles of HF self-management. The study surveyed 49 nurses who regularly provided care to patients with HF at a hospital in the southeastern United States. A 20-item, true/false survey was administered to participants. Mean HF self-management knowledge score was 15.97 (79.85% correct). Consistent with previous studies, nurses scored lowest on knowledge related to transient dizziness (16.3% answered correctly), daily weight monitoring (36.2% answered correctly), and asymptomatic hypotension (58.3% answered correctly). Findings confirm previous work suggesting that nurses may not be adequately prepared to educate patients with HF about self-management. (Prog Cardiovasc Nurs. 2007;22:190-195)

- by Leslie Davis
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- Nursing, Educational Measurement, Self Care, Heart Failure

Wastewater treatment sludge contains valuable nutrients, yet represents a residue problem due to the amount of heavy metals, which is one of the factors preventing the use of sludge as fertilizer. In Sweden, the government has a declared aim of closing the ecocycles of nutrients to arable land, while at the same time the existing limit values are among the lowest in the world. This paper focuses on the opportunities for Swedish wastewater utilities (WWUs) to manage and reduce sources of heavy metals in order to get sludge approved and recycled.

- by Louise Sorme
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- Social Sciences, Recycling, Environmental Management, Wastewater Treatment

Little is known about hand hygiene practice in the long-term care setting. In this study, we observed 459 hand hygiene opportunities in 2 long-term care facilities in Hamilton, Ontario. Overall hand hygiene adherence was 14.7%, with a mean handwashing time of 15.9 seconds. Adherence varied by activity performed and the presence or absence of a sink. (Am J Infect Control 2008;36:492-4.) Although significant research has focused on hand hygiene issues in the acute care setting, little is known about hand hygiene in long-term care facilities. Proper hand hygiene may be the single most important, and least expensive, means of preventing health careassociated infections and the spread of antimicrobial resistance. 1 Increasing hand hygiene and understanding factors associated with adherence are extremely relevant in the long-term care setting, where the demand for care is expected to increase significantly in the near future 2 and the patient population and environment promote both the development of infection and transmission of infectious agents. 3 One study of handwashing and glove use in a long-term care facility found that potential microbial transmission occurred in 82% of interactions observed and that handwashing was performed for every required instance during an interaction in only 4% of those interactions. We used direct observation methods to measure the adherence to hand hygiene among health care workers in 2 long-term care facilities in Hamilton, Ontario, Canada. We also assessed factors associated with hand hygiene adherence.

- by Soo Chan Carusone
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- Nursing, Long Term Care, Control, Health Services Research

Nuts are known for their hypocholesterolaemic properties; however, to achieve optimal health benefits, nuts must be consumed regularly and in sufficient quantity. It is therefore important to assess the acceptability of regular consumption of nuts. The present study examined the long-term effects of hazelnut consumption in three different forms on 'desire to consume' and 'overall liking'. A total of forty-eight participants took part in this randomised cross-over study with three dietary phases of 4 weeks: 30 g/d of whole, sliced and ground hazelnuts. 'Overall liking' was measured in a three-stage design: a pre-and post-exposure tasting session and daily evaluation over the exposure period. 'Desire to consume' hazelnuts was measured during the exposure period only. Ratings were measured on a 150 mm visual analogue scale. Mean ratings of 'desire to consume' were 92 (SD 35) mm for ground, 108 (SD 33) mm for sliced and 116 (SD 30) mm for whole hazelnuts. For 'overall liking', the mean ratings were 101 (SD 29) mm for ground, 110 (SD 32) mm for sliced and 118 (SD 30) mm for whole hazelnuts. Ground hazelnuts had significantly lower ratings than both sliced (P#0·034) and whole hazelnuts (P,0·001), with no difference in ratings between sliced and whole hazelnuts (P$ 0·125). For each form of nut, ratings of 'overall liking' and 'desire to consume' were stable over the exposure period, indicating that not only did the participants like the nuts, but also they wished to continue eating them. Therefore, the guideline to consume nuts on a regular basis appears to be a sustainable behaviour to reduce CVD.

- by Andrew Gray
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- Nutrition and Dietetics, Diet, Animal Production, Food Sciences

Context: Trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin were until recently the two drugs recommended in clinical guidelines in Israel for empiric treatment of uncomplicated urinary tract infection (UTI) in women. Objectives: The objective of this study is to evaluate the economic impact of physician nonadherence to these recommendations. Design setting and patients: Data were derived from the electronic patient records of the Leumit Health Fund. Cases of women aged 18 to 75 with a diagnosis of acute cystitis or UTI that were empirically treated with antibiotics from January 2001 to June 2002 were identified. The final sample comprised 7738 physician-patient encounters. The proportion of cases treated with each individual drug was calculated, and the excess expenditure because of non-adherence to guidelines from the perspective of the Health Maintenance Organization (HMO) was evaluated using 5 days of therapy with nitrofurantoin as the reference treatment. Results: TMP-SMX was the most frequently prescribed drug (25AE81%), followed by nitrofurantoin (14AE71%) representing a 40AE52% rate of adherence to the guidelines. Drugs from the fluoroquinolone family were prescribed in 22AE82% of cases. Cost of treatment in approximately 70% of the cases exceeded the expected cost of the guideline therapy. Conclusions: Suboptimal adherence to the guidelines resulted in a significant and avoidable waste of the health plan's resources in both drugs and money.

- by David Chinitz
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- Treatment, Adolescent, Urinary Tract Infections, Aged

As part of the Closing the Quality Gap: Revisiting the State of the Science series of the Agency for Healthcare Research and Quality (AHRQ), this systematic review sought to identify completed and ongoing evaluations of the comprehensive patient-centered medical home (PCMH), summarize current evidence for this model, and identify evidence gaps. We searched PubMed®, CINAHL®, and the Cochrane Database of Systematic Reviews for published English-language studies, and a wide variety of databases and Web resources to identify ongoing or recently completed studies. Two investigators per study screened abstracts and full-text articles for inclusion, abstracted data, and performed quality ratings and evidence grading. Our functional definition of PCMH was based on the definition used by AHRQ. We included studies that explicitly claimed to be evaluating PCMH and those that did not but which met our functional definition. Seventeen studies with comparison groups evaluated the effects of PCMH ...

- by Sheryl A Larson
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- Patient Safety, Palliative Care, Health Literacy, Medication Adherence

It is essential for children suffering from or at risk of lead poisoning to have regular follow-up, and specifically for their blood lead (Pb) levels to be monitored. The present study assessed the occurrence of late follow-up testing of blood lead levels in children in Greater Paris, and factors related to such delays. Since 1992, the SSSIILF has been systematically recording data on lead levels in blood tests conducted for screening and follow-up in Greater Paris. For Pb greater or equal to 45 microg/dL (Group 4), a further blood lead test has to be done within three weeks. For levels of 25 microg/dL < or = Pb < 45 microg/dL (Group 3) and 10 microg/dL < or = Pb < 25 microg/dL (Group 2), a second test must be done within 6 months. For Pb less than 10 microg/dL combined with one or more risk factors (Group 1: children at risk of poisoning), a second test is required within 6 to 12 months. Children aged 1 to 6 years who were screened between 1992 and 2002 were selected. T...

- by Robert Garnier
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- Child, Paris, Lead, Infant

Stroke patients experience multiple impairments which impair ability to eat and render them vulnerable to the deleterious sequelae of malnutrition. This study aimed to develop, implement and evaluate evidence-based guidelines for nutrition support following acute stroke using a multifaceted change management strategy. Methods: Prospective quasi-experimental design. Documentation of two groups of 200 acute stroke patients admitted to medical and care of the elderly wards of an acute NHS Trust in South London was surveyed using a checklist before and after implementation of 24 guidelines for nutritional screening, assessment and support. Guidelines were based on systematic literature review and developed by consensus in a nurse-led multiprofessional group; implemented via a context-speci¢c, multifaceted strategy including opinion leaders and educational programmes linked to audit and feedback. Sta¡ outcomes: Compliance with guidelines by doctors, nurses, therapists. Patient outcomes: Changes in Barthel Index scores and Body Mass Index in hospital, infective complications, length of stay, discharge destination. Results: Statistically signi¢cant improvements in compliance with 15 guidelines occurred in the post-test group. Infective episodes showed a signi¢cant reduction in the post-test group but other patient outcomes were una¡ected. Conclusions: Implementation of evidence-based guidelines for nutritional support following acute stroke using a multifaceted strategy was associated with improvements in documented practice and selected patient outcomes.

The purpose of this paper is to describe potential improvements in patient safety resulting from design decisions in the development of a computerized decision support system (DSS) for managing opioid therapy for chronic noncancer pain. ATHENA-DSS is an automated decision support system developed in a collaboration between Stanford University and the U.S. Department of Veterans Affairs (VA) to increase guideline-adherent prescribing and to change physician behavior. Based on data in patients' computerized medical record and knowledge of the clinical domain encoded in a knowledge base, the system gives patient-specific recommendations to primary care providers at the point of care. ATHENA-Opioid Therapy is based on a previous system, ATHENA-Hypertension, and is designed to follow the VA/Department of Defense clinical practice guideline for the management of opioid therapy for chronic noncancer pain. We describe the rationale for development of decision support system elements and a graphical user interface to increase patient safety during primary care treatment for chronic pain. The ATHENA-Opioid Therapy system focuses on reducing patient risk in four main ways by: (1) identifying patients with comorbidities or concurrent prescriptions that raise risk for overdose and recommending more conservative dosing; (2) identifying patients with mental health problems that increase risk of medication abuse and recommending referral to psychiatric care and close monitoring; (3) assisting doctors with complex pharmacologic calculations to reduce the risk of mistakes when initiating, titrating, or switching medications; and (4) presenting relevant information to clinicians in an easy-to-use format. We describe a system evaluation plan that we believe is essential to ensure that deployment of ATHENA-Opioid Therapy leads to improvements in patient safety and increases in guideline-concordant prescribing, and we discuss the limitations of this system for patient safety efforts.

- by Samson Tu
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- Primary Care, Mental Health, Patient Safety, Chronic Pain

Healthcare-associated infection is a major safety issue affecting the quality of care of hundreds of millions of patients every year in both developed and developing countries. To meet the goal of ensuring patient safety across healthcare settings around the globe, the World Health Organization launched the World Alliance for Patient Safety in October 2004. Healthcare-associated infections were identified as a fundamental work priority and selected as the topic of the First Global Patient Safety Challenge launched by the Alliance. Under the banner "Clean Care is Safer Care", the Challenge aims at implementing several actions to reduce healthcareassociated infections worldwide, regardless of the level of development of healthcare systems and the availability of resources. Implementation strategies include the integration of multiple interventions in the areas of blood safety, injection safety, clinical procedure safety, and water, sanitation and waste management, with the promotion of hand hygiene in healthcare as the cornerstone. Several initiatives have been undertaken to raise global awareness and to obtain country commitment to support action on this issue. The new Guidelines on Hand Hygiene in Health Care, including the most consistent scientific evidence available, have been issued in an advanced draft form. An implementation strategy is proposed therein to provide solutions to overcome obstacles to improvement in compliance with hand hygiene practices, together with a range of practical tools for use in

- by Liam Donaldson
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- Patient Safety, Global Health, Control, Hospital Infection
- by Roland Valdes
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- Clinical Chemistry, Medical Biotechnology, Clinical Sciences, Guideline Adherence

Temporal trends in the incidence of opportunistic diseases (ODs) related to acquired immunodeficiency syndrome (AIDS) were studied during 1989-1997 in 1115 outpatients infected with human immunodeficiency virus (331 of whom had AIDS) in a hospital in Madrid, Spain. We analyzed the effect of adherence to antiretroviral therapy and Pneumocystis carinii pneumonia (PCP) prophylaxis on the incidence of OD. Diseases that showed a significant decreasing trend were esophageal candidiasis, pulmonary and extrapulmonary tuberculosis, and cerebral toxoplasmosis. Patients who adhered to antiretroviral therapy had a smaller risk of OD. Patients who adhered to PCP prophylaxis had a reduced risk of cerebral toxoplasmosis and PCP. A reduction in the incidence of AIDS-related ODs was observed, mainly in patients who underwent prophylaxis. Adherence to antiretroviral treatment and PCP prophylaxis was associated with a reduction in the risk of disease.

- by Jesus Castilla
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- Epidemiology, Statistical Analysis, Treatment, Infectious Diseases
- by Cary Kaufman
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- Program Evaluation, Quality of Mental Health Care, Quality Improvement, Medicine

BackgroundPhysical activity (PA) brief advice in health care is effective at getting individuals active. It has been suggested that one in four people would be more active if advised by a GP or nurse, but as many as 72% of GPs do not discuss the benefits of physical activity with patients.AimTo assess the knowledge, use, and confidence in national PA and Chief Medical Officer (CMO) health guidelines and tools among GPs in England.Design and settingOnline questionnaire-based survey of self-selecting GPs in England that took place over a 10-day period in March 2016.MethodThe questionnaire consisted of six multiple-choice questions and was available on the Doctors.net.uk (DNUK) homepage. Quotas were used to ensure good regional representation.ResultsThe final analysis included 1013 responses. Only 20% of responders were broadly or very familiar with the national PA guidelines. In all, 70% of GPs were aware of the General Practice Physical Activity Questionnaire (GPPAQ), but 26% were no...

- by Dr Justin Varney
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- Health Services Research, Family Practice, Medicine, England

Troubling deficits exist in palliative care (PC) of older adults under the prevailing ''terminal care''-oriented model. We previously described a PC model-TLC-that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and Team-oriented, Longitudinal, and Collaborative and Comprehensive. We present results of the Palliative Care in Assisted Living pilot, comparing two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents in Sacramento, California, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects enrolled (mean age 85), 58 in the more and 23 in the less intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice care. A total of 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives. We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p ¼ 0:04). Our pilot study had methodological limitations that could account for the lack of significant outcome effects. In this context, and given the

- by Tony Jerant
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- Anthropology, Palliative Care, California, Needs Assessment

Asthma is a common problem with a prevalence rate increasing every year. However, not all asthmatic patients receive appropriate treatment, partly due to the disease entity or patients' compliance, and partly due to physicians' knowledge and disposition in terms of treatment. This study was designed to investigate the current status of asthma treatment among clinicians in different practice settings, particularly regarding the acceptance of and adherence to asthma treatment guidelines and asthma patient education. Questionnaires were distributed by randomized sampling to doctors throughout the entire country. The questionnaire had six parts, measuring the following: 1) the use of different kinds of medication in the treatment of asthma; 2) adherence to asthma treatment guidelines; 3) the use of inhaled corticosteroids as part of management; 4) the use of peak flow meters in monitoring asthma; 5) relative efficiency in treating asthma; and 6) the use of a referral system, from general practitioners to specialists. There were 531 respondents out of 1,000 questionnaires distributed. The results revealed the following: 1) 20.2% of physicians use oral corticosteroids for maintenance therapy; 2) 31.8% of physicians do not follow asthma treatment guidelines; 3) 77.2% of physicians use inhaled corticosteroids for maintenance therapy (physicians in medical centers and regional hospitals use inhaled corticosteroids more frequently than private practitioners); 4) 51% of doctors do not use peak flow meters to monitor asthma symptoms because of prohibitive costs; 5) approximately 80% of clinicians have confidence in dealing with asthma problems; and 6) 29.2% of general practitioners do not refer patients to asthma specialists unless there is poor control or a need for further evaluation. Adherence to asthma treatment guidelines is poor, and such guidelines need to be popularized or simplified. There are still many discrepancies among doctors at different levels of hospitals. Re-education and review of asthma knowledge is necessary to keep clinical practitioners at the forefront of standard practice.

- by Li-Chi Chiang
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- Immunology, Asthma, Taiwan, Specialization

Background.-The American Academy of Pediatrics (AAP) has published clinical practice guidelines for the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). However, implementation of guidelines has been notoriously difficult to... more

Objective: To examine self-reported alcohol consumption and relationships between consumption, awareness of the 2009 NHMRC guidelines of no more than two standard drinks per day, drinking in excess of the guideline threshold and... more

- by Robin Room
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- Adolescent, Applied Economics, Alcohol Drinking, Young Adult

In a controversial expansion of workplace civil rights, the 1990 Americans with Disability Act (ADA) extended anti-discrimination protection to individuals with bmental impairments.Q One of the most critical barriers to the employment of individuals with mental disabilities is the degree of social stigma such disabilities incur, and there is compelling evidence that employers have stigmatizing attitudes and have discriminated against those with mental disabilities. This study examines the role played by stigma in employers' response to the 1990 Americans with Disability Act (ADA). A stratified sample of one hundred ninety employers were surveyed in 1996-1997 in a major Southern metropolitan area. Telephone interviews were completed with one hundred seventeen employers (response rate of 61.6%). The article describes employers' experiences with employees with mental disabilities and accommodations, specific employment practices, and attitudes towards those with mental disabilities. Stigma played an important role in conformity to the ADA (operationalized as either hiring or having specific recruiting policies for hiring individuals with mental disabilities). Furthermore, employers expressing coercive (fear of a lawsuit) as opposed to normative (belief that it is the right thing to do) rationales for compliance were more likely to hold stigmatized attitudes. Employers' beliefs about mental disability form a crucial foundation for truly supportive work environments (those that value difference and diversity), and further research is needed to determine if over time the ADA is successful in changing attitudes as well as behavior.

- by Teresa Scheid
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- Law, Stigma, Employment, Work Environment

In response to the paper by Keown andJochemsen in which the latest empirical data concerning euthanasia and other end-of-life decisions in the Netherlands is discussed, this paper discusses three points. The use of euthanasia in cases in which palliative care was a viable alternative may be taken as proof of a slippery slope. However, it could also be interpreted as an indication of a shift towards more autonomy-based end-of-life decisions. The cases of non-voluntary euthanasia are a serious problem in the Netherlands and they are only rarely justifiable. However, they do not prove the existence of a slippery slope. Persuading the physician to bring euthanasia cases to the knowledge of the authorities is a problem of any euthanasia policy. The Dutch notification procedure has recendy been changed to reduce the underreporting ofcases. However, many questions remain.

- by Johannes Van Delden
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- Social Change, Applied Ethics, Decision Making, Medical Ethics

Background. The growing burden of neonatal mortality associated with hospital-acquired neonatal sepsis in the developing world creates an urgent need for cost-effective infection-control measures in resource-limited settings. Methods. Using a before-and-after comparison design, we measured how rates of staff hand-hygiene compliance, colonization with drug-resistant pathogens (defined as ceftazidime-and/or gentamicin-resistant gramnegative bacilli and drug-resistant gram-positive cocci), bacteremia, and overall mortality changed after the introduction of a simplified package of infection-control measures at 2 neonatal intensive care units (NICUs) in Manila, The Philippines. Results. Of all 1827 neonates admitted to the NICU, 561 (30.7%) arrived from delivery already colonized with drug-resistant bacteria. Of the 1266 neonates who were not already colonized, 578 (45.6%) became newly colonized with drug-resistant bacteria. Of all 1827 neonates, 358 (19.6%) became bacteremic (78.2% were infected with gram-negative bacilli) and 615 (33.7%) died. Of 2903 identified drug-resistant colonizing bacteria, 85% were drugresistant gram-negative bacilli (predominantly Klebsiella species, Pseudomonas species, and Acinetobacter species) and 14% were methicillin-resistant Staphylococcus aureus. Contrasting the control period with the intervention period at each NICU revealed that staff hand-hygiene compliance improved (NICU 1: relative risk, 1.3; 95% confidence interval 1.1-1.5; NICU 2: relative risk, 1.6; 95% confidence interval, 1.4-2.0) and that overall mortality decreased (NICU 1: relative risk, 0.5; 95% confidence interval, 0.4-0.6; NICU 2: relative risk, 0.8; 95% confidence interval, 0.7-0.9). However, rates of colonization with drug-resistant pathogens and of sepsis did not change significantly at either NICU. Discussion. Nosocomial transmission of drug-resistant pathogens was intense at these 2 NICUs in The Philippines; transmission involved mostly drug-resistant gram-negative bacilli. Infection-control interventions are feasible and are possibly effective in resource-limited hospital settings. Nosocomial infections contribute a growing, yet underappreciated, share of neonatal mortality in the developing world [1]. Poor hand-hygiene practices [2, 3], reuse of single-use medication vials and devices [4], and inadequate sterilization of medical equipment [5] are key proximate events that facilitate transmission of

- by Socorro Mendoza
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- Philippines, Medicine, Biological Sciences, Colonization

This is an 'open access' paper available free to all on BioMedCentral. Click the link above. Background The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice. It offers a framework for process evaluation and also for comparative studies of complex interventions. It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice. Methods A formal theory structure is used to define the model, and its internal causal relations and mechanisms. The model is broken down to show that it is consistent and adequate in generating accurate description, systematic explanation, and the production of rational knowledge claims about the workability and integration of complex interventions. Results The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or in...

Multidrug-resistant organisms are an emerging threat in South Africa (SA). [1] Inappropriate prescriptions of broad-spectrum antimicrobials, multiple drug combinations, prolonged treatment and the lack of de-escalation are the main reasons, and Mendelson et al. warn that we are on course towards an era of untreatable bacterial infections. [2] Indiscriminate prescribing is common in SA intensive care units (ICUs), [3] driven by the fear that selecting the wrong antimicrobial to treat nosocomial infections will result in treatment failure and an increased mortality rate. [4,5] Ultrabroad-spectrum combination therapy (U-bSCT), whereby the initial empiric choice covers all possible pathogens, has been used injudiciously, with as many as 10 anti-infectives having been prescribed simultaneously. This policy is hazardous and promotes the development of multidrugresistant (MDR) pathogens. [6] Strategies to minimise the development of resistance (such as class restriction, [7] antibiotic cycling ('crop rotation') [8] and antimicrobial stewardship [9]) have been proposed. Unfortunately,

- by Khine /Han
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- Evidence Based Medicine, Adolescent, Child, Candidiasis

Knowledge about compliance with recommendations derived from the positional statement of the European Society of Endocrine Surgeons on modern techniques in primary hyperparathyroidism surgery and the Third International Workshop on management of asymptomatic primary hyperparathyroidism is scarce. Our purpose was to check it on a bi-national basis and determine whether management differences may have impact on surgical outcomes. An online survey including questions about indications, preoperative workup, surgical approach, intraoperative adjuncts, and outcomes was sent to institutions affiliated to the endocrine surgery divisions of the National Surgical Societies from Spain and Portugal. A descriptive evaluation of the responses was performed. Finally, we assessed the correlation between the different types of management with the achievement of optimal results, defined as a cure rate equal or greater than the median of all interviewed institutions. Fifty-seven hospitals (41 Spanish, 16 Portuguese) answered the survey. First-ordered imaging tests were neck ultrasound and sestamibi scan. Facing negative or non-concordant results, 44 % of surgeons ordered additional tests before first-time surgery, and 84 % before reoperations. When indicated, selective parathyroidectomy was an acceptable option for 95 % of institutions as first-time surgery and for 51 % in reoperations. Intraoperative parathormone measurements were used by 92 % of departments. The surgical outcomes were good in most institutions (median cure rate 97 %) and were influenced mostly by the presence of an endocrine surgery unit in the surgical department (p = 0.038). Practice of Iberian endocrine surgeons is consistent with current recommendations on surgery for primary hyperparathyroidism, with variability in some areas.

- by João Capela Costa and +2
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- Spain, Portugal, Clinical Sciences, Surveys and Questionnaires

Background: Although hand hygiene is the most important measure in the prevention of nosocomial infection, adherence to recommendations among health care workers (HCW) is low. Evaluation of compliance with hand hygiene was carried out in a Spanish teaching hospital. Methods: In 2005, adherence to hand hygiene was evaluated hospital wide through direct observation, collecting data on hand hygiene carried out whenever indicated (opportunity for hand hygiene). Compliance was defined as handwashing/disinfection in an opportunity for hand hygiene according to hospital protocols. The results were analyzed using mixed effects models, with the HCW observed as the random effect. Results: A total of 1254 opportunities for hand hygiene were observed in 247 HCWs. Mean compliance was 20%. Although few differences were observed among types of HCW, compliance varied according to hospital area (69% in the intensive care unit [ICU]) and timing with respect to patient contact (compliance after contact was twice that before contact). Multivariate analyses revealed a protective odds ratio (OR) for nonadherence in ICUs (OR, 0.04; 95% confidence interval (95% CI): 0.01-0.10) and after patient contact (OR, 0.25; 95% CI: 0.17-0.38).

- by Eduard Molins and +1
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- Nursing, Spain, Infection Control, Public health systems and services research

Participants in substance abuse research may be vulnerable for multiple reasons. International research ethics guidelines and policy statements require that researchers provide extra protections when conducting research with vulnerable subjects, but it is uncertain which measures best protect vulnerable individuals. Concerns about vulnerability have been translated into only the vaguest regulatory requirements, and very little empirical data exist to guide researchers and ethics review committee members who want to protect participants. This article reviews two bodies of substance abuse research ethics literature. First, "normative" articles, that is, articles that discuss ethical issues that may arise in substance abuse research, are discussed. The resulting taxonomy of ethical issues then guides a review of empirical studies on issues like the informed consent process and the use of financial incentives in substance abuse research. While the ethical issues in substance abuse research are numerous and well-documented, the evidentiary base for addressing these issues is inadequate. If any one major theme emerged from the existing studies, it is that many well-intentioned, protectionist concerns -about recruitment incentives, consent comprehension, and drug administration studies -are not supported by empirical data. While these findings are at best tentative, they suggest how research on research ethics might ultimately benefit participants.

- by James DuBois
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- Literature, Research Ethics, Professional Ethics, Informed Consent

Background: The importance of theory in underpinning interventions to promote effective professional practice is gaining recognition. The Medical Research Council framework for complex interventions has assisted in promoting awareness and adoption of theory into study design. Human error theory has previously been used by high risk industries but its relevance to healthcare settings and patient safety requires further investigation. This study used this theory as a framework to explore non-prescription medicine supply from community pharmacies. The relevance to other healthcare settings and behaviours is discussed. Method: A 25% random sample was made of 364 observed consultations for non-prescription medicines. Each of the 91 consultations was assessed by two groups: a consensus group (stage 1) to identify common problems with the consultation process, and an expert group (stages 2 and 3) to apply human error theory to these consultations. Paired assessors (most of whom were pharmacists) categorised the perceived problems occurring in each consultation (stage 1). During stage 2 paired assessors from an expert group (comprising patient safety experts, community pharmacists and psychologists) considered whether each consultation was compliant with professional guidelines for the supply of pharmacy medicines. Each noncompliant consultation identified during stage 2 was then categorised as a slip/lapse, mistake, or violation using human error theory (stage 3). Results: During stage 1 most consultations (n = 75, 83%) were deemed deficient in information exchange. At stage 2, paired assessors varied in attributing non-compliance to specific error types. Where agreement was achieved, the error type most often selected was ''violation'' (n = 27, 51.9%, stage 3). Consultations involving product requests were less likely to be guideline compliant than symptom presentations (OR 0.30, 95% CI 0.10 to 0.95, p = 0.05). Conclusions: The large proportion of consultations classified as violations suggests that either pharmacy staff are unaware of professional guidelines and thus do not follow them (therefore these acts would not be violations), or that they knowingly violate the guidelines due to reasons that need further research. The methods presented here could be used in other healthcare settings to explore healthcare professional behaviour and to develop strategies to promote patient safety and effective professional practice.

- by Margaret Watson
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- Patient Safety, Evidence Based Medicine, Health Services Research, Scotland

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.

- by ian graham
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- Nursing, Communication, Organizational Culture, Leadership

Este estudio establece la relacion entre el cumplimiento de las directrices gubernamentales de actividad fisica (una hora de actividad fisica moderada o vigorosa, MVPA, cinco veces a la semana), la condicion fisica saludable, la calidad de la dieta y otras variables en una muestra de escolares de Extremadura (Espana). Se ha utilizado un t-test para calcular las diferencias de condicion fisica entre los grupos, de acuerdo con el cumplimiento de las mencionadas directrices de actividad fisica. Se ha establecido un coeficiente de regresion logistica multinomial para determinar las diferencias entre el grupo con mejor condicion fisica (= percentil 75) y el grupo con peor condicion fisica (= percentil 25), en funcion del sexo, indice de masa corporal, actividad fisica, indice mediterraneo de calidad de la dieta y tamano de la poblacion. El cumplimiento de las directrices de actividad fisica se relaciona con mejor fuerza de prension en la mano izquierda (p <0,05), mayor potencia de las...

- by Raúl Martínez-Santos
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- Nutrition and Dietetics, Health Promotion, Medicine, Spain

Objective: To design an instrument composed of domains that would demonstrate physical therapy activities and generate a consistent index to represent the quality of care in physical therapy. Methods: The methodology Lean Six Sigma was used to design the tool. The discussion involved seven different management groups staff. By means of brainstorming and Cause & Effect Matrix, we set up the process map. Results: Five requirements composed the quality of care index in physical therapy, after application of the tool called Cause & Effect Matrix. The following requirements were assessed: physical therapist performance, care outcome indicator, adherence to physical therapy protocols, measure whether the prognosis and treatment outcome was achieved and Infrastructure. Conclusion: The proposed design allowed evaluating several items related to physical therapy service, enabling customization, reproducibility and benchmarking with other organizations. For management, this index provides the...

- by Paola Andreoli
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- Program Evaluation, Brazil, Benchmarking, Reproducibility of Results

Compared with the history of national guideline development, the science attached to implementation of guidelines is relatively new. Effectiveness of a highly evidence-based guideline, such as the 8th Joint National Committee recommendations on the treatment of high blood pressure, depends on successful translation into clinical practice. Implementation relies on several steps: clear and executable guideline language, audit and feedback attached to education of practitioners charged with carrying out the guidelines, team-based care delivery, credibility of blood pressure measurement, and measures to address therapeutic inertia and medication adherence. An evolving role of the electronic health record and patient empowerment are developments that will further promote implementation of the hypertension guideline. Further research will be needed to assess the efficacy and cost effectiveness of various implementation tools and strategies.

- by Daniel Lackland
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- Communication, Medication Adherence, Electronic Health Records, California

Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve... more

- by Charles Pozner
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- Emergency Medicine, Biology, Medicine, Multivariate Analysis

Using a multiple case study design, this article explores the translation process that emerges within Ontario long-term care (LTC) homes with the adoption and implementation of evidence-based clinical practice guidelines (CPGs). Within-organization knowledge translation is referred to as knowledge application. We conducted 28 semi-structured interviews with a range of administrative and care staff within 7 homes differentiated by size, profit status, chain membership, and rural/urban location. We further undertook 7 focus groups at 5 locations, involving a total of 35 senior clinical staff representing 15 homes not involved in earlier structured interviews. The knowledge application process that emerges across our participant organizations is highly complex, iterative, and reliant upon a facility's knowledge application capacity, or absorptive capacity to effect change through learning. Knowledge application capacity underpins the emergence of the application process and the advancement of knowledge through it. We find that different elements of capacity are important to different stages of the knowledge application process. Capacity can preexist, or can be acquired. The majority of the capacity elements required for successful knowledge application in the LTC contexts we studied were organizational. It is essential for managers and practitioners therefore to conceptualize and orchestrate knowledge application initiatives at the organization level; organizational leaders (including clinical leaders) have a vital role to play in the success of knowledge application processes.

- by Whitney Berta and +1
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- Sociology, Anthropology, Long Term Care, Evidence Based Medicine

Malaria treatment policy recommends regular monitoring of drug utilization to generate information for ensuring effective use of anti-malarial drugs in Nigeria. This information is currently limited in the retail sector which constitutes a major source of malaria treatment in Nigeria, but are characterized by significant inappropriate use of drugs. This study analyzed the use pattern of anti-malarial drugs in medicine outlets to assess the current state of compliance to policy on the use of artemisinin-based combination therapy (ACT). A prospective cross-sectional survey of randomly selected medicine outlets in Enugu urban, southeast Nigeria, was conducted between May and August 2013, to determine the types, range, prices, and use pattern of anti-malarial drugs dispensed from pharmacies and patent medicine vendors (PMVs). Data were collected and analyzed for anti-malarial drugs dispensed for self-medication to patients, treatment by retail outlets and prescription from hospitals. A ...

- by Brian O Ogbonna
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- Medical Microbiology, Malaria, Health Policy, Nigeria
- by Philippe CABARROT
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- Documentation, Quality Improvement, Benchmarking, France

Coping with domestic violence against children and adolescents from the perspective of primary care nurses Enfrentamento da violência doméstica contra crianças e adolescentes na perspectiva de enfermeiros da atenção básica

- by Liliana Scatena
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- Domestic Violence, Fear, Brazil, Adolescent

scorecard diabetes prevalence in long term care tight blood sugar control in long term care residents a b s t r a c t Objective: The objectives of this article are to (1) describe the outcomes of a diabetes care program in a long term care facility dedicated to diabetes excellence and (2) compare the relevant outcome variables of research published between 2007 and 2012 with the results found in the studied facility. Design: Three year retrospective chart review of the facility's residents with comparison to extant literature. Participants: A total of 224 resident charts within the studied facility were reviewed. Residents with a diagnosis of diabetes, or who were on diabetes medications, or whose fasting blood sugars exceeded 126 mg/dL on 2 occasions, and whose length of stay exceeded 6 months, were tracked for adherence to diabetes guidelines (n ¼ 48). Participant outcomes from relevant studies in the literature were compared to these 48 participants' outcomes. Intervention: All levels of staff in the studied facility were educated in general diabetes care. A nurse practitioner was contracted to provide medical care for all diabetic residents (with primary care provider approval). A scorecard for adherence to diabetes guidelines was completed by the nurse practitioner. Over a 3 year period following the education program and scorecard implementation, a chart review of all residents was completed by a consulting diabetes educator/nurse practitioner/nurse faculty member and 6 undergraduate nursing students. Results: In general, the nursing home in the present study compared favorably with other relevant studies, demonstrating lower A1C levels, tracking blood sugars more regularly, monitoring blood pres sure and lipids more regularly, having a greater percentage of patients on lipid lowering medications among those in need, more appropriate use of sliding scale insulin, greater adherence to recommen dations regarding diet, and had more patients who fit criteria on preventive anticoagulation. Discussion: The results for the studied facility were very similar, often better, when compared with the most current nursing home literature. Areas of weakness provided focused strategic planning for the facility. Regrettably, the research is sparse, and evidence supporting guideline adherence data is often missing, making data comparison difficult. This model of care, linking health care agencies with academia, could offer a supportive and affordable method for identifying responses to evidence based care guidelines. Conclusion: This narrative review points to the need for continued work in the application of evidence based guidelines in long term care, specifically in the area of interventions that must be adjusted to the needs of the nursing home population, with increased awareness in maintaining or improving quality of life.

- by kathy hager
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- Long Term Care, Diet, Treatment Outcome, Medicine