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Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists
Abstract
Adherence to clinical practice guidelines is highly variable. Our objective was to review barriers to physicians' adherence to evidence-based guidelines (EBGs) for preventing ventilator-associated pneumonia (VAP).
A questionnaire was administered to 110 opinion leaders on VAP from 22 countries to indicate whether 33 pharmacologic and nonpharmacologic practices that had been listed in a recent publication had been implemented in their ICUs. If these prevention strategies were not used, the respondents were asked to indicate one of seven reasons for nonadherence, with the objective of identifying barriers to adherence to EBGs.
The overall nonadherence rate was 37.0%. The nonadherence rate was 25.2% for strategies recommended for clinical use, compared with 45.6% for strategies with less effectiveness (odds ratio [OR], 1.80). Pharmacologic strategies had a higher degree of nonadherence than nonpharmacologic strategies (OR, 2.92). Nonadherence to recommendations graded A, B, C, D, and U based on an objective assessment of the consistency of the supporting evidence was 41.3%, 35.7%, 16.0%, 45.7%, and 20.8%, respectively. The most common reasons for nonadherence were the following: disagreement with interpretation of clinical trials (35%); unavailability of resources (31.3%); and costs (16.9%).
We conclude that nonadherence to EBGs for preventing VAP was common and largely uninfluenced by the degree of evidence. A rational approach toward improving VAP guideline adherence should take into account the heterogeneous factors that influence physician adherence to them.
... Encontramos que solamente un 35,9% de los kinesiólogos encuestados realiza siempre la higiene oral con antiséptico, en comparación con lo hallado por Rello et al., quienes vieron que un 55,4% de los profesionales en salud llevan a cabo esta medida. 24 Por el contrario, la encuesta de Sierra et al. arrojó como resultado que el 93% de las UTI españolas públicas cumplían con esta práctica. 15 Con respecto a lo reportado por la bibliografía sobre esta medida, en la última revisión de Cochrane, los autores concluyeron que el enjuague bucal con clorhexidina se asocia a una caída del riesgo de desarrollar NAVM de un 25% a un 19%. ...
... Este resultado se asemeja al reportado por otros autores, quienes obtuvieron valores de adherencia del 97% y 85%. 18,24 Elevación de la cabecera de la cama En cuanto al posicionamiento de la cabecera entre 30° y 45°, el 93,6% de nuestra muestra efectuó dicha medida en concordancia con la encuesta realizada por Sierra et al. en España, con un 93% de complacencia. 15 Por otro lado, De Rosa et al. mostraron porcentajes que oscilaron entre el 73% y 78%. ...
... En los estudios de Kaynar et al. y Rello et al. fue encontrada una adherencia al drenaje sistematizado de la condensación de los circuitos del 70,1% y 75,4 %, respectivamente. 18,24 Debido a que la American Association for Respiratory Care recomienda tener en cuenta las limitaciones y contraindicaciones de los sistemas de humidificación pasivo y activo, la elección del dispositivo no debe basarse en el control infectológico, 33 motivo por el cual en nuestra encuesta no preguntamos cuál era el dispositivo utilizado con mayor frecuencia en las UTI participantes. ...
Objetivo: Conocer la adherencia a las medidas no farmacológicas de los kinesiólogos/as que trabajan en una Unidad de Terapia Intensiva (UTI) de adultos, para prevenir la neumonía asociada a la ventilación mecánica (NAVM) en establecimientos de salud públicos y privados de la Ciudad Autónoma de Buenos Aires (CABA). Materiales y método: Se realizó un estudio observacional descriptivo de tipo encuesta online entre octubre y diciembre de 2018. Se incluyeron kinesiólogas/os que trabajan en una UTI de adultos ubicada geográficamente en CABA. Se los invitó a participar del estudio enviando la encuesta mediante la herramienta Survey Monkey®. Resultados: Se analizaron un total de 97 encuestas, de las cuales un 80,4% correspondían a roles asistenciales y un 19,6% a roles de coordinación. Se obtuvo una adherencia del 12,8% a las medidas de prevención no farmacológicas de la NAVM por parte de los kinesiólogos asistenciales. Conclusión: La baja adherencia a las medidas de prevención obtenida en nuestra encuesta, refleja la brecha que existe entre la práctica diaria de los kinesiólogos intensivistas y las recomendaciones de las guías basadas en la evidencia.
... Высокая летальность опреде ляет ее медицинское значение -10-25 % вне ОРИТ и 25-70 % в ОРИТ [33,34]. НП значительно ухудша ет течение заболевания, увеличивает летальность, длительность госпитализации и стоимость лечения [13,35,36]. Особенно остро проблема стоит в ОРИТ хирургического профиля [28,37]. ...
... Удельный вес НП ИВЛ составляет от 16,8 до 68 % в структуре госпитальной пневмонии [2,18,36,[38][39][40]. Многоцентровое европейское исследование, прове денное в 1995 г., показало, что НП ИВЛ являлось наи более часто встречаемой НИ у больных, требующих ИВЛ [24]. ...
... Данные, касающиеся влияния НП ИВЛ на исхо ды, атрибутивную летальность, меры профилактики и опубликованные в многочисленных исследованиях, часто отличаются друг от друга. Это связано с разным дизайном исследований: особенностями националь ной системы здравоохранения, типом больницы и ОРИТ, тяжестью состояния больных [22,29,30,36,39,40,42,43]. ...
... Each correct answer scored one mark and the wrong answer zero. The total score was arbitrarily classified as Very good (25-30), Good (19)(20)(21)(22)(23)(24), Average (13)(14)(15)(16)(17)(18), Poor (7)(8)(9)(10)(11)(12) and Very poor (0-6). The highest score was thirty and the lowest score was zero. ...
... Whereas, the Structured observational practice checklist had 20 items to assess nurses' practice regarding the care bundle on prevention of ventilator-associated pneumonia. The practice score was arbitrarily classified as Very good (16)(17)(18)(19)(20), Good (11-15), Average (6)(7)(8)(9)(10) and Poor (0-5). The highest score was twenty and the lowest score was zero. ...
... An observational study conducted by Rello J, et al. concluded that educational programs can reduce the chance of VAP. Thus, nurses working in intensive care units must be educated regarding VAP prevention strategies [17]. Study results of Al-Khader, et al. revealed that the practice level of participants (42.5%) was fair, 32.5% had poor and 2.5% of them had good practice level [10]. ...
Background: Ventilator-Associated pneumonia (VAP) is a major cause of morbidity and mortality and is the second most common nosocomial infection among critically ill patients, affecting 6% to 52% and can reach to 76% in some specific hospital settings. VAP can prolong the pa-tient's length of stay in the hospital and thereby the financial burden. Knowledge and practice run parallel therefore, the present study was conducted to assess the effectiveness of structured teaching Program on knowledge and practice regarding care bundle on prevention of ventilator-associated pneumonia among nurses.
... Each correct answer scored one mark and the wrong answer zero. The total score was arbitrarily classified as Very good (25-30), Good (19)(20)(21)(22)(23)(24), Average (13)(14)(15)(16)(17)(18), Poor (7)(8)(9)(10)(11)(12) and Very poor (0-6). The highest score was thirty and the lowest score was zero. ...
... Whereas, the Structured observational practice checklist had 20 items to assess nurses' practice regarding the care bundle on prevention of ventilator-associated pneumonia. The practice score was arbitrarily classified as Very good (16)(17)(18)(19)(20), Good (11-15), Average (6)(7)(8)(9)(10) and Poor (0-5). The highest score was twenty and the lowest score was zero. ...
... An observational study conducted by Rello J, et al. concluded that educational programs can reduce the chance of VAP. Thus, nurses working in intensive care units must be educated regarding VAP prevention strategies [17]. Study results of Al-Khader, et al. revealed that the practice level of participants (42.5%) was fair, 32.5% had poor and 2.5% of them had good practice level [10]. ...
Background of the study: Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality and is the second most common nosocomial infection among critically ill patients, affecting 6% to 52% and can reach to 76% in some specific hospital settings. VAP can prolong the patient’s length of stay in hospital and thereby the financial burden. Knowledge and practice run parallel therefore, present study was conducted to assess the effectiveness of structured teaching programme on knowledge and practice
regarding care bundle on prevention of ventilator associated pneumonia among nurses.Materials and methods: One group pretest and posttest design was adopted to accomplish the objectives. Convenient sampling technique was used to select samples.The sample consists of 30 nurses working in ICU of tertiary care hospital. The pretest and post-test assessment of knowledge and practice of the patients was carried out using the structured knowledge questionnaire and structured observational practice checklist. The obtained data was analyzed and interpreted using descriptive and inferential statistics. Results: The mean pre-test knowledge and practice score was 7.79 and 10.33 respectively. However, the post-test knowledge and practice score were 24.1 and 17.16 that reveals improvement knowledge and practice after structured teaching program. The calculated t test value was 14.95 and 16.72 for knowledge and practice which is highly significant at 0.05 level.Conclusion: The study findings concluded that the Structured Teaching Program has improved the knowledge and practice of nurses regarding care bundle on prevention of ventilator associated pneumonia.
... The tools developed by researchers ( O'Grady et al., 2011;Pittet et al., 2008;Rello et al., 2002;Rosenthal et al., 2006;Safdar et al., 2005;Usluer et al., 2006) were used. Five forms were included. ...
... Care bundle (Form V) was prepared based on evidence-based interventions in related literature (Berenholtz et al., 2004;Pittet et al., 2008;Rello et al., 2002;Rosenthal et al., 2006;Safdar et al., 2005;Usluer et al., 2006) and guidelines (the Centers for Disease Control and Prevention/ CDC, Turkish Society of Hospital Infections and Control/ HİDER, Arman et al., 2008;O'Grady et al., 2011;Alp et al.;Arda et al., 2012;Çetinkaya-Şardan et al., 2013). Care bundle consists of most common three chapter of HAIs, CA-UTIs, VAP and CLABSIs. ...
... A study conducted at various centers of Europe reported a low 53% compatibility rate with VAP prevention rules. Deficient materials (31%) and cost increase concerns (16.9%) in the ICU were considered as the main reasons for incompatibility (Rello et al., 2002). In our study, compatibility with the VAP was 44.4% in April −June and 40.0% in July − September. ...
Background:
Healthcare-associated infections extend hospitalization time, increase treatment costs and increase morbidity-mortality rates.
Objectives:
To evaluate the efficacy of a care bundle aimed at preventing three most frequent intensive care unit-acquired infections.
Materials and method:
This quasi-experimental study occurred in an 18-bed tertiary care intensive care unit at a university hospital in Turkey. The sample consisted of 120 patients older than 18years and receiving invasive mechanical ventilation therapy, or had a central venous catheter or urinary catheter. The study comprised three stages. In stage one, the intensive care unit nurses were trained in infection measures, VAP, CA-UTIs and CLABSIs sections of the care bundle. In stage two, the trained nurses applied the care bundle and received feedback on any problematic issues. In stage three, the nurses' compatibility and efficacy of the infection prevention care bundle on the infection rates of VAP, CA-UTIs and CLABSIs were evaluated over three 3-month periods.
Results:
Over 1000 ventilation days, ventilator-associated pneumonia infection rates were 23.4, 12.6, and 11.5, during January-March, April-June and July-September, respectively, with January-March and April-June showing a significant decrease (χ2=6.934, p=0.031). The central line-associated bloodstream infection rates were 8.9, 4.2, and 9.9 per 1000 catheter days, during January-March, April-June and July-September, respectively, but were not significantly different based on pair-wise comparisons (p>0.05). The catheter-associated urinary tract infection rates were higher during July-September (6.7/1000 catheter days) compared to January-March (5.7/1000 catheter days) and April-June (10.4/1000 catheter days) but the differences were not significant (p>0.05).
Conclusions:
The infection rates decreased with increased compatibility of the care bundle prepared from evidence-based guidelines.
... In this study, using kinetic beds, endotracheal tubes with extra lumens for the drainage of subglottic secretions and semi-recumbent position were correctly responded by 90.4%, 65.4% and 82.7% of the respondents. Also, the studies semi-recumbent positioning was well acknowledged to prevent VAP (19,(23)(24)(25). Like our study, in Blot's study, 60% of the respondents knew that draining subglottic secretions decreases the risk for pneumonia. ...
... The frequency of correct answers for each item in Blot's study is better than our study and as follows: the frequency of changing ventilator circuits as 48.6%; the frequency of changing humidifiers 13.3%; and the frequency of changing the suction system as 19.6% (21). In the studies by Rello et al (25) and Ricart et al (19) the heat and moisture exchangers were changed on a daily basis in 59 and 75%, respectively. Sierra et al found that in 75% of the ICUs, ventilator circuits were changed every 72 hr or later (24). ...
... One might question the importance of pure knowledge versus the application degree in practice. We believe that thorough understanding of the recommended strategies supports the adherence and overcomes potential barriers as previously identified (19,21,25). Additionally, increasing the average level of knowledge has been the first step in successful multifaceted educational programs (27). ...
... As a result of the high mortality, morbidity, and hospital expenses associated with VAP, a number of guidelines have been published since the 1980s to prevent and control it (Rello et al., 2002;Society & America, 2005). Efforts continued by health organizations and societies such as the European Centre for Disease Prevention and Control (ECDC) and the CDC to set and update evidence-based guidelines (EBGs) and strategies that markedly proved to minimize the occurrence of VAP and improve outcomes, and the quality of care (QoC) delivered to MVPs ((IHI). ...
... In spite of the existence of clinical practice guidelines for preventing VAP, these guidelines are not consistently followed (Cason et al., 2007;Ricart et al., 2003). Reported levels of compliance with and proper use of strategies vary widely in various contexts, across health systems, specialties, and nurses, ranging from 20% to nearly 100% (Beattie et al., 2012;Bird et al., 2010;Rello et al., 2002). Several studies showed that nurses generally exhibit low NC, which could be attributable to diverse factors (Aloush et al., 2018;Aloush & Al-Rawajfa, 2020;Jahansefat et al., 2016;Jam et al., 2018). ...
Background: Healthcare organizations provide evidence-based guidelines designed to support nurses in preventing ventilator-associated pneumonia (VAP) in intensive care units (ICUs), but there are barriers to compliance with such guidelines. This review explicitly explored evidence of compliance barriers among critical care nurses.
Methods: A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EBSCO databases for relevant English-language studies published between January 2003 and June 2022, focused on barriers to nursing compliance with VAP prevention guidelines. Data was reported according to the Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines.
Results:
230 publications were screened, resulting in 53 full-text articles being retrieved after removing duplicates, of which 13 relevant to the aims of the review and meeting the inclusion criteria were included for data extraction. One was a qualitative study, while the remainder were quantitative. Simple descriptive content analysis identified the barriers to critical care nurses’ compliance with VAP prevention guidelines, and categorized them as: (1) work environment barriers (e.g ., lack of equipment and supplies ; lack of staff and time; lack of educational support ; and ineffective supportive system ); (2) nurse-related barriers ( limited personal competencies ); and (3) situation-related barriers ( patient health, discomfort, and adverse events ).
Conclusions: This review revealed important evidence on barriers to VAP prevention guidelines compliance. Nurses are challenged mainly by work-environmental barriers along, with the presence of nurse and situational barriers. It is evident from the findings that further qualitative and mixed-methodology follow-up studies are recommended to further explore the issues in depth. Healthcare leaders must be aware of these barriers and integrate work policies that assist in overcoming them, to increase compliance.
... As a result of the high mortality, morbidity, and hospital expenses associated with VAP, a number of guidelines have been published since the 1980s to prevent and control it (Rello et al., 2002;Society & America, 2005). Efforts continued by health organizations and societies such as the European Centre for Disease Prevention and Control (ECDC) and the CDC to set and update evidence-based guidelines (EBGs) and strategies that markedly proved to minimize the occurrence of VAP and improve outcomes, and the quality of care (QoC) delivered to MVPs ((IHI). ...
... In spite of the existence of clinical practice guidelines for preventing VAP, these guidelines are not consistently followed (Cason et al., 2007;Ricart et al., 2003). Reported levels of compliance with and proper use of strategies vary widely in various contexts, across health systems, specialties, and nurses, ranging from 20% to nearly 100% (Beattie et al., 2012;Bird et al., 2010;Rello et al., 2002). Several studies showed that nurses generally exhibit low NC, which could be attributable to diverse factors (Aloush et al., 2018;Aloush & Al-Rawajfa, 2020;Jahansefat et al., 2016;Jam et al., 2018). ...
Background: Healthcare organizations provide evidence-based guidelines designed to support nurses in preventing ventilator-associated pneumonia (VAP) in intensive care units (ICUs), but there are barriers to compliance with such guidelines. This review explicitly explored evidence of compliance barriers among critical care nurses.
Methods: A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EBSCO databases for relevant English-language studies published between January 2003 and June 2022, focused on barriers to nursing compliance with VAP prevention guidelines. Data was reported according to the Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines.
Results:
230 publications were screened, resulting in 53 full-text articles being retrieved after removing duplicates, of which 13 relevant to the aims of the review and meeting the inclusion criteria were included for data extraction. One was a qualitative study, while the remainder were quantitative. Simple descriptive content analysis identified the barriers to critical care nurses’ compliance with VAP prevention guidelines, and categorized them as: (1) work environment barriers (e.g ., lack of equipment and supplies ; lack of staff and time; lack of educational support ; and ineffective supportive system ); (2) nurse-related barriers ( limited personal competencies ); and (3) situation-related barriers ( patient health, discomfort, and adverse events ).
Conclusions: This review revealed important evidence on barriers to VAP prevention guidelines compliance. Nurses are challenged mainly by work-environmental barriers along, with the presence of nurse and situational barriers. It is evident from the findings that further qualitative and mixed-methodology follow-up studies are recommended to further explore the issues in depth. Healthcare leaders must be aware of these barriers and integrate work policies that assist in overcoming them, to increase compliance.
... Typically, the contents of a CPG, describe disease-specific process flows, patients' summaries, medical decisions, content specific alerts, and protocols, which provide the necessary ingredients for dealing with a wide variety of medical situations [4,5]. However, the adherence rate of CPGs, is highly dependent on their nature, and the applicable clinical scenario, which leads to an effective usage rate between 20% and 100% [6]. Some of the common reasons for non-adherence to these guidelines, include, a lack of awareness for the healthcare practitioners, and the difficulty in understanding the large textual content of the CPGs in a limited time, during the clinical practice [6][7][8]. ...
... However, the adherence rate of CPGs, is highly dependent on their nature, and the applicable clinical scenario, which leads to an effective usage rate between 20% and 100% [6]. Some of the common reasons for non-adherence to these guidelines, include, a lack of awareness for the healthcare practitioners, and the difficulty in understanding the large textual content of the CPGs in a limited time, during the clinical practice [6][7][8]. ...
Clinical Practice Guidelines (CPGs) aim to optimize patient care by assisting physicians during the decision-making process. However, guideline adherence is highly affected by its unstructured format and aggregation of background information with disease-specific information. The objective of our study is to extract disease-specific information from CPG for enhancing its adherence ratio. In this research, we propose a semi-automatic mechanism for extracting disease-specific information from CPGs using pattern-matching techniques. We apply supervised and unsupervised machine-learning algorithms on CPG to extract a list of salient terms contributing to distinguishing recommendation sentences (RS) from non-recommendation sentences (NRS). Simultaneously, a group of experts also analyzes the same CPG and extract the initial patterns “Heuristic Patterns” using a group decision-making method, nominal group technique (NGT). We provide the list of salient terms to the experts and ask them to refine their extracted patterns. The experts refine patterns considering the provided salient terms. The extracted heuristic patterns depend on specific terms and suffer from the specialization problem due to synonymy and polysemy. Therefore, we generalize the heuristic patterns to part-of-speech (POS) patterns and unified medical language system (UMLS) patterns, which make the proposed method generalize for all types of CPGs. We evaluated the initial extracted patterns on asthma, rhinosinusitis, and hypertension guidelines with the accuracy of 76.92%, 84.63%, and 89.16%, respectively. The accuracy increased to 78.89%, 85.32%, and 92.07% with refined machine-learning assistive patterns, respectively. Our system assists physicians by locating disease-specific information in the CPGs, which enhances the physicians’ performance and reduces CPG processing time. Additionally, it is beneficial in CPGs content annotation.
... The study could provide important baseline information on the delivery of health care in Port Said hospital and the potential for improvements in health care quality. Similarly, Kinsman (2004) and Rello et al., (2002) studies have been conducted with the objectives of the using clinical pathways to improve quality of care, to reduce costs, and to decrease inappropriate variation in health care use (Kinsman, 2004& Rello et al., 2002. ...
... The study could provide important baseline information on the delivery of health care in Port Said hospital and the potential for improvements in health care quality. Similarly, Kinsman (2004) and Rello et al., (2002) studies have been conducted with the objectives of the using clinical pathways to improve quality of care, to reduce costs, and to decrease inappropriate variation in health care use (Kinsman, 2004& Rello et al., 2002. ...
... The effect of national guidelines in improving patient outcomes has been observed in other diseases, such as pneumonia, for which the implementation of clinical guidelines led to decreases in hospital costs, length of stay, and mortality. [29][30][31][32] Several hepatology associations have contributed with guidelines to improve care in patients with NAFLD. 4,25,33 The effect of these guidelines is invaluable and the recommendations should be disseminated to physicians in clinical practice and endorsed nationally. ...
Non-alcoholic fatty liver disease (NAFLD) affects 20–25% of the general population and is associated with morbidity, increased mortality, and elevated health-care costs. Most NAFLD risk factors are modifiable and, therefore, potentially amenable to being reduced by public health policies. To date, there is no information about NAFLD-related public health policies in the Americas. In this study, we analysed data from 17 American countries and found that none have established national public health policies to decrease NAFLD-related burden. There is notable heterogeneity in the existence of public health policies to prevent NAFLD-related conditions. The most common public health policies were related to diabetes (15 [88%] countries), hypertension (14 [82%] countries), cardiovascular diseases (14 [82%] countries), obesity (nine [53%] countries), and dyslipidaemia (six [35%] of countries). Only seven (41%) countries had a registry of the burden of NAFLD, and efforts to raise awareness in the Americas were scarce. The implementation of public health policies are urgently needed in the Americas to decrease the burden of NAFLD.
... In a study by Blot et al. (Blot et al., 2007), ICU nurses indicated that humidifier changes should be done every 48 hours. Rello et al. (Rello et al., 2002) and Ricart et al. (Ricart et al., 2003) reported that nurses often changed humidifier daily. In another study conducted with ICU nurses from 22 European countries, it was found that only 21% of nurses knew that humidifier changes should be done weekly (Labeau et al., 2008). ...
... Also, in mechanically ventilated patients, elevation of head end of the patient bed at 45 degrees has been proven to significantly reduce the incidence of aspiration and ventilator-associated pneumonia (VAP). 1 Indeed, ensuring head end elevation of at least 30 degrees is a part of almost all proposed VAP bundles that have documented lower VAP rates. 2 However, it has been seen that the application of this simple intervention remains low. 3 Reeve and Cook found that majority of mechanically ventilated patients were kept with angle of the bed elevated less than 30 degrees. 4 We believe that part of this low implementation is due to lack of knowledge, hospital practices, etc. While some ICU beds have a mechanical indicator (a small bead that moves along a scale on the side rail of the bed), in many ICUs and in hospital wards, the beds may not have any indicator of angle of head end elevation. ...
... Higher compliance rates were reported earlier for the central catheter care bundle (Caserta et al., 2012), and urinary catheter care bundle. For VAP compliance rates, comparable results, 53%, were reported from a previous European study (Rello et al., 2002). On the contrary, higher compliance rates than this one was reported by Morris et al. (2011). ...
Background: In resource-limited countries, device-associated infections (DAIs) pose a real threat to patient safety as one of the most significant causes of morbidity and mortality. Nevertheless, inadequate data from ICUs in the developing world is available. The study aimed to assess the compliance with the device care bundle and evaluate the impact of device care bundle implementation on the incidences rate of device-associated infections and the mortality rates. Health care workers' compliance with care bundles was observed. DAIs and mortality rates were calculated. Results: The compliance rate was (44/84; 52.4%) to each of ventilator care and central catheter care bundles and (45/84; 53.6%) to urinary catheter insertion care bundle. The incidence rate of total DAI was 35.3/1000 device-days. The overall crude excess mortality rates is 39.2% (relative risk, 5.7; 95% CI, 3.04-10.68; P <0.001) & 15.9% (relative risk, 2.91; 95% CI, 1.55-5.40; P <0.001), for DAIs and for non-infected cases respectively. Conclusion: A highly recommended practice is continuous monitoring of the device care bundle implementation. For ICU staff members, a pre-employment package of training must be provided.
... All health care providers involved in the care of patients on MV must be well educated in respect to the diagnosis and prevention of VAP as this has been shown to reduce the VAP rate 38,39 . However, studies have shown that despite all well-established guidelines, adherence to Evidence Based Guidelines (EBG) is poor among clinicians due to either unavailability of resources or cost or disagreement with the clinical trials 40,41 . ...
... Whereas barriers to implement guidelines among nurses and physicians have been assessed and reported for the prevention of and therapy for ventilator-associated pneumonia [8], less information is available on the effect of improving outcomes and the degree of compliance. The most common reasons for nonadherence were disagreement with the interpretation of clinical trials, unavailability of resources, and costs [9]. Due to the complexity and number of interventions, it has been suggested to use care bundles [10,11] with an emphasis on audits and feedback. ...
... 8 Unfortunately, data suggest that the implementation and dissemination of evidence-based guidelines is not universal. [9][10][11] Single-site studies conducted before the release of the NHLBI guideline also suggested that the ED treatment for sickle cell vaso-occlusive crises would not have met the guideline. [12][13][14][15] The Pediatric Emergency Care Applied Research Network (PECARN) Registry, a multicenter clinical repository of electronic health record data from 7 pediatric ED sites, is composed of more than 2.4 million overall pediatric ED visits annually. ...
Study objective:
The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network.
Methods:
We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years.
Results:
A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both).
Conclusion:
Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.
... The authors approached this topic by assembling a purposive multidisciplinary sample of respondents across three paediatric hospitals. The findings are consistent with prior studies in other countries describing favourable attitudes towards the goal of preventing HAI [28], lack of systematic infection prevention education [29,31] including hand hygiene [33], and the influence of constraints on financial resources [15,29,34] including staff shortages [31,32]. ...
Background:
Healthcare-associated infections (HAIs) in the neonatal intensive care unit (NICU) result in increased morbidity, mortality, and healthcare costs. Rates of HAIs in Greek NICUs are among the highest in Europe. There is a need to identify the factors that influence the transmission of HAIs and implementation of prevention interventions in this setting.
Aim:
To understand healthcare workers' perceptions about HAI prevention in Greek NICUs.
Methods:
We conducted qualitative interviews with NICU staff (physicians and nurses) and infection-prevention stakeholders (infectious diseases physicians and infection control nurses) working in three hospitals in Athens. Interviews were conducted in Greek, transcribed and translated into English, and analyzed using a modified grounded theory approach.
Findings:
Interviews were conducted with 37 respondents (20 physicians and 17 nurses). Four main barriers to HAI prevention were identified: (1) resource limitations leading to understaffing and cramped space; (2) low HAI prevention knowledge; (3) Greek-specific cultural norms, including hierarchy-driven decisions, a reluctance for public workers to do more than they are paid for, a belief that personal experience trumps evidence-based knowledge, and reactive rather than proactive approaches to societal challenges; and (4) lack of a national infection prevention infrastructure. Respondents believed that these barriers could be overcome through organized initiatives, high-quality HAI performance data, interpersonal interactions to build engagement around HAI prevention, and leveraging the hierarchy to promote change from the "top down."
Conclusion:
Implementing HAI prevention interventions in Greek NICUs will require consideration of contextual features surrounding the delivery of care, with particular attention paid to national culture.
... Adherence to clinical guidelines are critical to improving the quality of medical care. However, adherence to evidence-based clinical guidelines remain a challenge [1][2][3][4]. In the Intensive Care Unit (ICU), where the care needs of patients can be complex, evidence-based consensus guidelines have been developed. ...
Background
The use of evidence-based clinical practice guidelines improves the quality of patient medical care. Although the implementation of clinical guidelines can be a challenge, nutritional support is important for critically ill patients. This prospective observational study aimed to investigate the attention to and implementation of guidelines for nutritional support in an Intensive Care Unit (ICU) in China and to identify factors that determine attention to these guidelines.
Material/Methods
The study included 16 medical residents who were interviewed while working in an emergency Intensive Care Unit (ICU) during one month. A structured interview questionnaire on attention to patient nutritional guidelines was used. Interviews were conducted daily after an early ICU ward round, and residents were asked questions regarding each patient.
Results
The response rate from medical residents was 99.6% (455/457). The rate of attention to and implementation of nutritional support guidelines was 57.1% (260/455) and 73.1% (334/457), respectively. Multivariate logistic regression analysis showed that weekdays and weekends (OR, 0.59; 95% CI, 0.38–0.91), medical groups (OR, 0.67; 95% CI, 0.46–0.98), and the numbers of patients admitted (OR, 0.91; 95% CI, 0.85–0.97) were independently associated with attention to nutritional support guidelines by the residents.
Conclusions
Nutritional guidelines for patients in the ICU were not fully paid attention to by medical residents or implemented. The reasons included high work demands and lack of standardized training. Further studies are needed to determine whether measures to reduce workload and improve medical training can improve adherence to nutritional support guidelines in the ICU.
... It can either be used by healthcare providers or can be transformed to machine interpretable format to be part of the Clinical Decision Support System (CDSS) to support clinicians at the point of care. Despite the valuable goal and importance, the adherence rate of CPGs varies between 20% to 100% depending upon clinical scenario and the nature of the CPG [3]. The main hurdle in the adherence of CPGs is the current format (unstructured document) of the CPG and clinician/healthcare provider unawareness about CPGs. ...
Clinical Practice Guidelines (CPGs) are an essential resource for standardization and dissemination of medical knowledge. Adherence to these guidelines at the point of care or by the Clinical Decision Support System (CDSS) can greatly enhance the healthcare quality and reduce practice variations. However, CPG adherence is greatly impeded due to the variety of information held by these lengthy and difficult to parse text documents. In this research, we propose a mechanism for extracting meaningful information from CPGs, by transforming it into a structured format and training machine learning models including Naïve Bayes, Generalized Linear Model, Deep Learning, Decision Tree, Random Forest, and Ensemble Learner on that structured formatted data. Application of our proposed technique with the aforementioned models on Rhinosinusitis and Hypertension guidelines achieved an accuracy of 82.10%, 74.40%, 66.70%, 66.79%, 74.40%, and 83.94% respectively. Our proposed solution is not only able to reduce the processing time of CPGs but is equally beneficial to be used as a preprocessing step for other applications utilizing CPGs.
... College expectations and hospital requirements are futile if professional autonomy is interpreted as meaning that compliance is discretionary [39]. Previous studies have also suggested that doctors' poor compliance with guidelines, in general, reflects ignorance or skepticism about their effectiveness and/or an exaggerated confidence in their own judgment [40,41]. As Charani et al suggest: Senior doctors consider themselves exempt from following policy and practice, within a culture of perceived autonomous decision-making that relies more on personal knowledge and experience than formal policy [42]. ...
Background
Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers’ adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors’ IPC practices will contribute to development of new strategies to improve IPC, overall.
Methods
This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ IPC practices, using thematic analysis of data.
Results
Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.
Conclusions
Failure of healthcare and professional organisations to address doctors’ poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.
... 9 Physician adherence rates to clinical practice guidelines in general can range anywhere from 20% to 99%. [10][11][12] The discordance between evidence and prescriber practice has been bridged with success in primary care and acute settings, where education and protocols have decreased the number of opioid prescriptions. [13][14][15] However, even in the setting of a protocol, our study had only 70.6% adherence. ...
Context:
Surgeons write 1.8% of all prescriptions and 9.8% of all opioid prescriptions. Even small doses prescribed for short-term use can lead to abuse; thus, surgeons are uniquely able to combat the opioid epidemic by changing prescribing practices. As part of a department wide quality improvement project, we initiated a nonopioid protocol for all patients undergoing ambulatory breast surgery.
Objective:
To determine the feasibility of a nonopioid protocol for patients undergoing ambulatory breast surgery and to determine if patient-related factors contribute to surgeon adherence to a nonopioid protocol in ambulatory breast surgery.
Design:
Retrospective chart review of a prospectively collected database, with χ2 analysis and a multiple logistic regression model with the surgeon as the random effect.
Main outcome measure:
Protocol adherence.
Results:
A total of 180 patients, with a median age of 63 years (range = 18-95 years), were included. Of these, 127 (70.6%) did not receive opioids; in this group there were 2 hematomas (1.6%), and 3 patients required an opioid prescription (2.4%). Fifty-three (29.4%) were prescribed opioids against protocol; in this group, there was 1 hematoma (1.9%). The operating surgeon was the only variable independently correlated with protocol adherence (p < 0.0001). Age, race/ethnicity, surgery type, and history of long-term opioid use were not.
Conclusion:
Ambulatory breast surgery patients tolerated a nonopioid pain regimen well. Surgeons' decisions, rather than patient characteristics, primarily drove the choice of pain management in our study. We believe our protocol can be improved with stricter implementation and education, which must be balanced with practitioner independence.
... (17,20) The prevention and control of VAP are based on the education of CCUs health-care staff towards the problem and on the application of a series of clinical, organizational, and behavioral measures. (21) Alhirish et al., ...
Background: Critically ill patients in critical care units (CCUs) are at high risk for infections associated with increased morbidity, mortality, and health care costs. The overall infection rate in critically ill patients approaches 40% and may be as high as 50% or 60% in patients who remain in the CCU for more than 5 days. Ventilator-associated pneumonia (VAP) in mechanically ventilated patients ranges from 8% to 28%. VAP refers to an infection that develops during mechanical ventilation after 48 hours of intubation. Nurses play a pivotal role in decreasing patients’ risk of acquiring VAP. Keeping pace, in this instance, is really about turning focus back to the more basic aspects of critical care nursing. Evidence now demonstrates how important basic nursing care is to the prevention of VAP by using strategies for the prevention of VAP.
Objective: The aim of this study was to assess nurses’ compliance of evidence-based guidelines for preventing VAP in CCUs.
Methods: The study was conducted at the CCUs of Alexandria Main University Hospital namely, Casualty Intensive Care Unit (unit I) and General Intensive Care Unit (unit III). The sample of this study consisted of 60 nurses working in the previously mentioned CCUs. Two tools were used for data collection VAP Preventive interventions Observation Checklist (VAPPIOC) and VAP knowledge questionnaire (VAPKQ).
Results: Nurses had different levels of adherence for many nonpharmacologic strategies. All nurses responses to the questionnaire, rates and reasons for non adherence were addressed.
Conclusion: The most important barriers to implementation were environment-related. Other reasons for non-adherence were patient-related barriers being significantly important for nurses. Overall, the most important barriers to adherence were unavailability of resources. Our findings suggest the need for development of guidelines to reduce variability and the need to include the nursing point of view in these guidelines.
... VAP prevention guidelines were used in 64% of French ICUs while it was only 30% in Canadian ICUs [108]. Variability of adherence to evidence based guidelines is also reported by other authors where A c c e p t e d M a n u s c r i p t only 37% of intensive care physicians adhered to the guidelines [109]. Although each measure in the care bundle may not apply to all patients at all times, its daily reappraisal at patients' bedside must be reinforced. ...
Introduction:
Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
... The use of research evidence in clinical practice has advanced healthcare delivery from unpredictable and unproven practices to treatments based on rigorous research evidence to improve outcomes [1,2]. However, research use continues to be a challenge across all healthcare disciplines and settings [3][4][5], with over two-thirds of implementation efforts deemed unsuccessful [6]. For example, a recent cross-sectional survey revealed that only 12% of nurses and allied health professionals in the European Society of Cardiology used research-based evidence from guidelines in their practice [7]. ...
Background:
Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals.
Methods:
A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals' use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted.
Results:
The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices.
Conclusions:
This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care.
Trial registration:
PROSPERO CRD42014007660.
... From the existing literature, the unavailability of resources is a well-known barrier. 43,44 On the other hand, many HCPs raised concern over side effects of prevention measures (eg, head of bed elevation leading to increased need for catecholamines, belonging to component 'physical capability'). Some HCPs were subjectively concerned about the patient's well-being (eg, perception that head of bed elevation is uncomfortable for the patient, belonging to the component 'automatic motivation'). ...
Objective
Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.
Design
Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).
Setting
The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.
Patients and participants
Adherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.
Results
Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%–31%); oral care at 41% (95% CI, 36%–45%); sedation interruption at 81% (95% CI, 74%–85%); and subglottic suctioning at 88% (95% CI, 83%–92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component ‘reflective motivation’ (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to ‘physical capability’ (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, ‘restructuring environment’ and ‘enabling HCP’) emerged as means to overcome these barriers.
Conclusions
Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.
... Pneumonia: 1 if patient had (ICD-9 codes 481-483) on Medicare Part A claim for the index stay, 0 otherwise. 21 ...
Background:
Our objective is to estimate the effects associated with higher rates of renin-angiotensin system antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs), in secondary prevention for geriatric (aged >65 years) patients with new ischemic strokes by chronic kidney disease (CKD) status.
Methods and results:
The effects of ACEI/ARBs on survival and renal risk were estimated by CKD status using an instrumental variable (IV) estimator. Instruments were based on local area variation in ACEI/ARB use. Data abstracted from charts were used to assess the assumptions underlying the instrumental estimator. ACEI/ARBs were used after stroke by 45.9% and 45.2% of CKD and non-CKD patients, respectively. ACEI/ARB rate differences across local areas grouped by practice styles were nearly identical for CKD and non-CKD patients. Higher ACEI/ARB use rates for non-CKD patients were associated with higher 2-year survival rates, whereas higher ACEI/ARB use rates for patients with CKD were associated with lower 2-year survival rates. While the negative survival estimates for patients with CKD were not statistically different from zero, they were statistically lower than the estimates for non-CKD patients. Confounders abstracted from charts were not associated with the instrumental variable used.
Conclusions:
Higher ACEI/ARB use rates had different survival implications for older ischemic stroke patients with and without CKD. ACEI/ARBs appear underused in ischemic stroke patients without CKD as higher use rates were associated with higher 2-year survival rates. This conclusion is not generalizable to the ischemic stroke patients with CKD, as higher ACEI/ARBS use rates were associated with lower 2-year survival rates that were statistically lower than the estimates for non-CKD patients.
... Regarding ventilator bundles, Cook et al. [105] reported a 64 and a 30% compliance bundle care in two institutions, with multiple barriers observed: fear of adverse effects, lack of convincing benefit, nurse inconvenience, and cost. Rello et al. [106] reported disagreement with trials and lack of resources as the main reasons to non-adherence. ...
Purpose of Review
Ventilator-associated pneumonia (VAP) is still a common complication in intensive care units, being associated with higher costs, increasing hospital length of stay, duration of mechanical ventilation and use of antimicrobials. Ventilator care bundles are key measures to patient care quality improvement, and their implementation contributes to the reduction in the incidence of VAP. The current review focuses on preventive measures of VAP and a potential concept of zero VAP rate.
Recent Findings
Several reports have documented a decrease in VAP rate with the implementation of ventilator care bundles. Despite the improvement on VAP incidence, risk factors to VAP are numerous and although some are preventable, it is unachievable to eliminate the majority.
Summary
VAP is not always preventable and thus unlikely to reach zero rate. Several reports have documented a decrease in the incidence of VAP when a bundle is implemented. The major restrain to care bundles implementation is adherence; compliance to them is the achieving goal that can be reached by the use of a maximum of five interventions, with a strong effort on multidisciplinary education and continued feedback. Surveillance, prevention, and education remain a priority in critical care in order to minimize VAP.
... Furthermore, the standard nurse-to-patient ratio is 1:3 while nursing shifts last for 24 hours. Especially the latter contributes to an excessive workload which is associated with sub-optimal compliance with recommendations in infection prevention and indicated as a main barrier to comply with local protocols in ICUs (Rello et al., 2002;De Wandel et al., 2010;Lambert et al., 2013;Valencia et al., 2016;Battistella et al., 2017;De Wandel 2017;Piras et al., 2017;Sadule-Rios and Aguilera 2017;Velasquez Reyes et al., 2017). ...
Objectives:
We assessed the effect of a skin-protective terpolymer barrier film around the catheter insertion site on frequency of dressing disruptions and skin integrity issues (hyperaemia, skin irritation, residues of adhesives and moisture under the dressing). Secondary outcomes included colonisation of the central venous catheter (CVC) and rates of central line-associated bloodstream infection.
Research methodology:
A monocentric, open-label, randomised controlled trial was performed comparing a control group receiving standard transparent catheter dressings without the skin-protecting lotion and an intervention group receiving a transparent chlorhexidine-impregnated dressing with use of the skin-protective acrylic terpolymer barrier film (3M™ Cavilon™ No - Sting Barrier Film, 3 M Health Care, St. Paul, MN, USA).
Results:
Sixty patients were enrolled and randomised in the study accounting for 60 central venous catheters and a total of 533 catheter days. Dressing disruptions occurred more frequently and at sooner time point in the control group. Skin integrity issues were significantly less observed in the intervention group. No differences in CVC colonisation or central line-associated bloodstream infection were observed.
Conclusions:
The application of a barrier film creating a skin-protective polymer layer beneath transparent catheter dressings is associated with less dressing disruptions and skin integrity issues without altering the risk of infectious complications if used in combination with a chlorhexidine-impregnated catheter dressing.
... Varios autores han coincidido que las intervenciones basadas en retroalimentación y que involucren actividades de docencia han dado resultados pequeños a moderados [13][14][15][16][17][18][19] , incluso a nivel de terapia profesional a pacientes en el campo de la salud mental ha sido documentado, lo cual es coherente con la intervención que realizamos desde dos puntos de vista, el primero con el mejoramiento significativo en 6 meses de proceso y la nula conflictividad en el desarrollo del mismo. Paton ha demostrado que el simple hecho de tener datos e indicadores no ha generado mejoras sustanciales en calidad 20 , Zhele propone que los cambios deben incidir en el comportamiento de los profesionales directamente 21 lo cual es coherente con la preocupación de varios investigadores sobre la no utilización de Guías Clínicas [22][23][24] , en el estudio realizado, los indicadores son una parte del proceso, sin embargo, la mejora continua analizada antes y después es clave para la evolución de la gestión de la calidad. La calidad de un proceso de auditoria medica se ve facilitado en un ambiente académico, se había analizado como un proceso de gestión clínica 25 , sin embargo existe mucha evidencia de como la auditoria influye en ambientes académicos, directa e indirectamente 26-31 , esto se da por varias razones: el ambiente académico en si, la visión del proceso de auditoria como una herramienta de aprendizaje, la evidencia de mejora con las intervenciones a manera de resolución de problemas; por lo tanto debería validarse la eficiencia del proceso para ser incluido en espacios de docencia de manera formal. ...
... One study performed in France and Canada, applying seven strategies for the prevention of VAP, revealed that compliance with guidelines was low in both countries (Cook et al., 2000). In a similar study from Europe, compliance with recommendations was at the 37 % level (Rello et al., 2002). Therefore, training of all health personnel must be a precondition for infection control in all ICUs, and particularly units with limited resources, in order to increase compliance with these recommendations (Babcock et al., 2004). ...
Mechanical ventilation (MV) is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient's characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7%. Crude VAP mortality was 69% in the first period and 26% in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased MV days and enteral nutrition; risk factors determined in the first period were reintubation, central venous catheter (CVC) use and heart failure, and in the second period erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of health care-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programs, and standard procedures in patient interventions must be revised.
... It seems obvious that a high level of standard of care in intensive care units can only be achieved through a dedicated and well-trained nursing staff. Clearly, education is an elementary first step in quality improvement initiatives because it is a condition to ensure high levels of adherence with recommendations. 2 Unfortunately, poor adherence to evidence-based guidelines has been a concern for years, 3,4 and it has been hypothesized that poor knowledge may-at least in part-be responsible for inadequate compliance. It is well documented that knowledge does not guarantee adherence, but it is apparent that a lack of knowledge, per definition, impedes adherence. ...
... Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of VAP [12]. However, it has become clear that the mere presence of a guideline, while necessary, is rarely sufficient to promote widespread adoption and uptake [13][14][15][16][17][18][19][20][21][22][23]. It is unclear as to what extent these guidelines are currently followed in ICUs and what barriers may exist that impede the implementation of these guidelines. ...
Background:
Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of ventilator-associated pneumonia (VAP). However, the mere presence of guidelines is rarely sufficient to promote widespread adoption and uptake. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model framework, we undertook a study to understand barriers and facilitators to the adoption of the IDSA/ATS guidelines.
Methods:
We conducted surveys and focus group discussions of different health care providers involved in the management of VAP. The setting was medical-surgical ICUs at a tertiary academic hospital and a large multispecialty rural hospital in Wisconsin, USA.
Results:
Overall, we found that 55 % of participants indicated that they were aware of the IDSA/ATS guideline. The top ranked barriers to VAP management included: 1) having multiple physician groups managing VAP, 2) variation in VAP management by differing ICU services, 3) physicians and level of training, and 4) renal failure complicating doses of antibiotics. Facilitators to VAP management included presence of multidisciplinary rounds that include nurses, pharmacist and respiratory therapists, and awareness of the IDSA/ATS guideline. This awareness was associated with receiving effective training on management of VAP, keeping up to date on nosocomial infection literature, and belief that performing a bronchoscopy to diagnose VAP would help with expeditious diagnosis of VAP.
Conclusions:
Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.
... [28] Education of all healthcare provider results in better VAP prevention if recommendations for VAP prevention are properly followed. [29,30,31,32] VAP prevention bundles have been proposed to address the gap in implementation of guidelines. Ventilatory Support: Whenever possible avoid or limit the use of mechanical ventilation. ...
Ventilator-associated pneumonia (VAP) is a type of hospital acquired pneumonia commonly encountered in patients who receive mechanical ventilation and is associated with significant mortality and morbidity. VAP is associated with prolonged ventilation, increased antibiotic use, emergence of multidrug resistant organisms, prolonged critical care unit stay resulting in increased cost of care. It has been reported to occur in 9 to27 percent of all intubated patients. As per International Nosocomial Infection Control Consortium (INICC) report data summary, the overall rate of VAP was 13.6 per 1,000 ventilator days. Preventive measures, early diagnosis and treatment of VAP result in better outcome. The aim of this review was to search the literature for incidence, various risk factors, etiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. VAP is a commonly encountered nosocomial infection occurring in ventilated patients and is associated with increased mortality and morbidity. Outcome of patient with VAP depends on hospital setting, patient group, infection control policy, early diagnosis and judicious antibiotic use.
Background
A bundle is defined by IHI as a small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually. It is important to understand that a bundle is not simply a checklist to complete, it is a set of researched interventions that have been shown to work better when completed together. These interventions are usually already well known and utilized in practice by nurses or providers. A bundle places the priority on the entire set of interventions being completed for the at-risk patient.
Objective
The focus of this paper is to explain the principles of a bundle, the evidence supporting their utilization in practice, challenges associated with care bundles, how to overcome these challenges, and recommendations for future success.
Conclusions
A literature search on the implementation of bundles demonstrates several challenges to their use. Sustaining a comprehensive quality improvement approach within an institution can be challenging but with the guidelines outlined by IHI for requirements of a bundle and the implementation recommendations, great success can be obtained.
Objetivo: Evaluar la intervención de Auditoria Medica en un grupo residentes de posgrado de Medicina Familiar.
Materiales y métodos: Se realizó un estudio exploratorio, en donde se incluyó una cohorte de médicos y fueron evaluados en un periodo de 6 meses. Se incluyeron 1060 revisiones de actuaciones clínicas y se aplicó el formulario de auditoria medica de terreno validado en Ecuador. La inclusión de casos fue aleatoria inicialmente y posteriormente intencionada, de acuerdo a los procesos de reauditoría, esto para garantizar mayor efectividad.
Resultados y discusión: Se revisaron cuentes principalmente ambulatorias, el nivel de conflictividad fue prácticamente nulo, existió aceptación del proceso de auditoria médica en un ambiente docente, el porcentaje de apelaciones fue bajo (menos del 0,5%) y la presentación de casos de interés genero reuniones proactivas, con alta madurez profesional y de discusión científica.
En la evaluación clínica, se inicia con un puntaje promedio de calidad de 70% y se finaliza con 88%. Se lograron mejoras en casi todos los campos, especialmente en manejo no farmacológico y Captación activa del riesgo de los pacientes. En el manejo legal de la información clínica, se parte de un puntaje alto (más del 90%) debido a que los formularios son electrónicos y tienen controles de registro.
Conclusiones: La tendencia observada es de mejoramiento, gracias a la personalización de las intervenciones por la administración del hospital, los residentes y Auditoria.
La aceptación del proceso por parte de los auditados es buena, gracias al enfoque cooperativo y no punitivo en un contexto académico.
Estos resultados son alentadores y confirman la validez, efectividad y eficiencia de los procesos de evaluación y monitoreo de la Calidad a través de Auditoria Medica integral en un medio docente. Es importante resaltar que el proceso debe ser continuo para lograr efectividad de la intervención.
Purpose: Prolonged ventilation leads to a higher incidence of ventilator-associated pneumonia (VAP), resulting in weaning failure and increased medical costs. The aim of this study was to analyze clinical results and prog-nostic factors of VAP in patients with blunt chest trauma.
Methods: From 2007 to 2011, one hundred patients undergoing mechanical ventilation for more than 48 hours were divided into two groups: a VAP-negative group, (32 patients, mean age; 53 years, M:F=25:7) and a VAP-positive group, (68 patients, mean age; 60 years, M:F=56:12). VAP was diagnosed using clinical symptoms, radiologic findings and microorganisms. The injury severity score (ISS), shock, combined injuries, computerized tomographic pulmonary findings, transfusion, chronic obstructive lung disease (COPD), ventilation time, stay in intensive care unit (ICU) and hospital stays, complications such as sepsis or disseminated intravascular coagulation (DIC) and microorganisms were analyzed. Chi square, t-test, Mann-Whitney U test and logistic regression analysies were used with SPSS 18 software.
Results: Age, sex, ISS, shock and combined injuries showed no differences between the VAP-negative group and-positive group (p>0.05), but ventilation time, ICU and hospital stays, blood transfusion and complications such as sepsis or DIC showed significant differencies (p<0.05). Four patients(13%) showed no clinical symptoms eventhough blood cultures were positive. Regardless of VAP, mortality-related factors were shock (p=0.036), transfusion (p=0.042), COPD (p=0.029), mechanical ventilation time (p=0.011), ICU stay (p=0.032), and sepsis (p=0.000). Microorgnisms were MRSA(43%), pseudomonas(24%), acinetobacter(16%), streptococcus(9%), kleb-siela(4%), staphillococus aureus(4%). However there was no difference in mortality between the two groups.
Conclusion: VAP itself was not related with mortality. Consideration of mortality-related factors for VAP and its aggressive treatment play important roles in improving patient outcomes.
The intensive care unit (ICU) is the hospital’s hot zone for healthcare-associated infection (HAI), especially ventilator-associated pneumonia, central line-associated bloodstream infection, catheter-associated urinary tract infection and surgical site infection. Evidence-based guidelines to prevent these Big Four are widely available, but healthcare professionals’ compliance is recognised as limited. This chapter discusses the basics of HAI prevention and proposes strategies to improve adherence to evidence-based prevention guidelines to promote a timely and successful ICU discharge by prevention of complications.
Hospital infection prevention and control (IPC) is often regarded by doctors as mundane and unnecessarily rigid, but the continued occurrence of preventable healthcare‐associated infections, increasing antimicrobial resistance (to which hospitals are major contributors) and rare, but potentially devastating hospital outbreaks of emerging infectious diseases, suggest that IPC must be taken seriously. Healthcare professionals often fail to comply with effective, evidence‐based IPC practices and there is ample evidence that doctors, generally, do so less consistently than nurses. However, doctors' practices are highly variable, apparently because of a perceived entitlement to clinical autonomy. In practice, most doctors observe safe IPC practices, most of the time. However, some are ignorant or dismissive of IPC policies and some respond angrily, when reminded. Among a small proportion of senior consultants, negative attitudes to IPC are perceived by their peers to correlate with a more general failure to meet their public hospital commitments, apparently because of conflicting demands, including private practice. The fact that breaches of IPC practice have significant, although often hidden, consequences indicates a need for continued improvement based on new strategies that might include: better surveillance, to identify and inform doctors of the true burdens of healthcare‐associated infections; professional self‐reflection on falsely dichotomous claims of medical professionalism namely: clinical autonomy versus regard for patient welfare by complying with ‘rules’ designed to protect them; and review of the consequences of recent changes in healthcare delivery, including proliferation of multiple, part‐time consultant contracts at the expense of public hospital culture and status.
Purpose: This study aimed to define the behavioral determinants influencing the decision of intensivists to consult a poison center (PC) when managing patients with calcium channel blocker (CCB) poisoning.
Material and methods: Semi-structured interviews were conducted involving a convenience sample of 18 intensivists. Two independent reviewers analyzed the interview responses using the Theoretical Domains Framework. Based on the impact and frequency of the reported behaviors, we selected the most relevant domains likely to influence intensivists’ decision to consult a PC for CCB poisoning.
Results: Beliefs influencing physicians positively to consult a PC for CCB poisoning were identified in the following domains: knowledge (e.g., lower level of evidence), social or professional role and identity (e.g., high credibility attributed to the PC), reinforcement (e.g., multiple drug poisoning, infrequent or potentially lethal poisoning, medicolegal considerations), and behavioral regulation (e.g., facilitated access of PC to patient’s hospital chart, direct communication with a toxicologist). Beliefs deterring physicians from consulting a PC for CCB poisoning were identified in the following domains: knowledge (e.g., better awareness of recommendations decreases tendency to call), goals (e.g., priority for patient stabilization), and memory, attention, and decision process (e.g., cognitive overload due to an unstable patient).
Conclusion: This qualitative study identified potential behavioral targets that future implementation strategies should address to improve collaboration between PCs and intensivists. In light of our results, the Québec PC now asks clinicians if the poisoned patient is unstable prior to collecting any other information. When necessary, a teleconference with the toxicologist is proposed earlier than before.
Past research in procedure following has primarily concentrated on the effect of procedure-related factors on procedure compliance and non-compliance. Non-compliance is generally considered to be uniformly negative, rather than the outcome that results from other factors. However, there is a general consensus that procedures are not designed for all situations, and that non-compliance can improve outcomes under certain situations. It is therefore important to understand procedure following based on outcomes and not only procedure compliance or non-compliance. To that end, a framework and taxonomy for understanding procedure following has been developed that enables researchers to focus on the outcome of following procedures, not simply on compliance and non-compliance.
Introduction:
Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning.
Methods:
Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning.
Results:
Positive beliefs were identified in the following domains: "behavioral regulation" (e.g., algorithm for adjustment of perfusions), "belief about capabilities" (e.g., confidence about being able to manage HIET), "belief about consequences" (e.g., fear of clinical deterioration), and "reinforcement" (e.g., clinical instability). Negative beliefs were identified in the following domains as "nature of behavior" (e.g., preference for vasopressors over HIET) and "environmental context and resources" (e.g., accessing dextrose 50% and increased nurse workload).
Conclusion:
This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.
Data S1. Medical chart procurement, abstraction, and quality measurement.
Data S2. Covariate definitions for Medicare claims data analysis of ACEI/ARB effectiveness after ischemic stroke.
Data S3. Instrument strategy background.
Data S4. 2‐stage least squares (2SLS) instrumental variable estimator background.
Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7–8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.
Objetivos: Este estudo é uma descrição do desenvolvimento de uma estratégia de auditoria médica baseada na garantia da provisão de qualidade usando ferramentas de monitoramento participativo em uma tentativa de gerar cooperação entre o auditor e o auditado no primeiro nível de serviços de Atenção Primária de Saúde do Ministério da Saúde Pública do Equador. Métodos: Desenvolvimento e implementação de uma metodologia, testada em campo, baseada em uma descrição dos resultados (estudo de corte transversal). Resultados: No início do processo, a pontuação de relevância clínica, em geral, não superava 45% e os riscos legais não excediam 65%. Progressivamente, observa-se um aumento na pontuação; adicionalmente, obtiveram-se resultados próprios de percepção deste processo por parte dos auditados, tendo menos resistência em menos de 5% dos casos, talvez devido ao caráter participativo do processo. Conclusão: O processo de auditoria médica é essencial para a identificação de problemas, mas também precisa ser um proceso ativo, com intervenção e resolução dos mesmos. A Auditoria Médica identifica problemas ocultos para os tomadores de decisão e diminui a resistência à inclusão de estratégias para a melhoria da qualidade.
OBJETIVO:
Evaluar la intervención de Auditoria Medica en un grupo residentes de posgrado de Medicina Familiar.
MATERIALES Y MÉTODOS:
Se realizó un estudio exploratorio, en donde se incluyó una cohorte de médicos y fueron evaluados en un periodo de 6 meses. Se incluyeron 1060 revisiones de actuaciones clínicas y se aplicó el formulario de auditoria medica de terreno validado en Ecuador. La inclusión de casos fue aleatoria inicialmente y posteriormente intencionada, de acuerdo a los procesos de reauditoría, esto para garantizar mayor efectividad.
RESULTADOS Y DISCUSIÓN
Se revisaron cuentes principalmente ambulatorias, el nivel de conflictividad fue prácticamente nulo, existió aceptación del proceso de auditoria médica en un ambiente docente, el porcentaje de apelaciones fue bajo (menos del 0,5%) y la presentación de casos de interés genero reuniones proactivas, con alta madurez profesional y de discusión científica.
En la evaluación clínica, se inicia con un puntaje promedio de calidad de 70% y se finaliza con 88%. Se lograron mejoras en casi todos los campos, especialmente en manejo no farmacológico y Captación activa del riesgo de los pacientes. En el manejo legal de la información clínica, se parte de un puntaje alto (más del 90%) debido a que los formularios son electrónicos y tienen controles de registro.
CONCLUSIONES:
La tendencia observada es de mejoramiento, gracias a la personalización de las intervenciones por la administración del hospital, los residentes y Auditoria.
la aceptación del proceso por parte de los auditados es buena, gracias al enfoque cooperativo y no punitivo en un contexto académico.
Estos resultados son alentadores y confirman la validez, efectividad y eficiencia de los procesos de evaluación y monitoreo de la Calidad a través de Auditoria Medica integral en un medio docente. Es importante resaltar que el proceso debe ser continuo para lograr efectividad de la intervención.
PALABRAS CLAVE:
Auditoría médica, docencia, mejoramiento continuo, calidad
Introduction
Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies.
Methods
Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year.
Results
Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs.
Conclusions
Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
Introduction:
Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies.
Methods:
Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year.
Results:
Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs.
Conclusions:
Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
BACKGROUND
Healthcare workers (HCWs) lack familiarity with evidence-based guidelines for the prevention of healthcare-associated infections (HAIs). There is good evidence that effective educational interventions help to facilitate guideline implementation, so we investigated whether e-learning could enhance HCW knowledge of HAI prevention guidelines.
METHODS
We developed an electronic course (e-course) and tested its usability and content validity. An international sample of voluntary learners submitted to a pretest (T0) that determined their baseline knowledge of guidelines, and they subsequently studied the e-course. Immediately after studying the course, posttest 1 (T1) assessed the immediate learning effect. After 3 months, during which participants had no access to the course, a second posttest (T2) evaluated the residual learning effect.
RESULTS
A total of 3,587 HCWs representing 79 nationalities enrolled: 2,590 HCWs (72%) completed T0; 1,410 HCWs (39%) completed T1; and 1,011 HCWs (28%) completed T2. The median study time was 193 minutes (interquartile range [IQR], 96–306 minutes)
The median scores were 52% (IQR, 44%–62%) for T0, 80% (IQR, 68%–88%) for T1, and 74% (IQR, 64%–84%) for T2. The immediate learning effect (T0 vs T1) was +24% (IQR, 12%–34%; P <.001), and a residual effect (T0 vs T2) of +18% (IQR 8–28) remained ( P <.001). A 200-minute study time was associated with a maximum immediate learning effect (28%). A study time >300 minutes yielded the greatest residual effect (24%).
CONCLUSIONS
Moderate time invested in e-learning yielded significant immediate and residual learning effects. Decision makers could consider promoting e-learning as a supporting tool in HAI prevention.
Infect Control Hosp Epidemiol 2016;37:1052–1059
This chapter addressed the following background issues: evidence-based medicine, the empirically supported treatment debate, what constitutes evidence, and competency. The National Council of Schools and Programs in Professional Psychology (NCSPP) educational model was discussed including the following components: relationship, assessment, intervention, consultation and education, management and supervision plus research and evaluation. Six specific foundational competencies were considered including their essential components, behavioral anchors, and assessment methods that indicate readiness for practicum, internship, and practice. These foundational competencies include: reflective practice and self-assessment, scientific knowledge and methods, relationships, individual and cultural diversity, knowledge of ethical and legal standards and policies and interdisciplinary systems. The following six functional competencies were discussed: assessment-diagnosis-case conceptualization, intervention, consultation, research and evaluation, supervision and teaching, plus management and administration. Essential components with behavioral anchors and assessment methods that indicate readiness for practicum, internship, and practice were identified. What being expert entails was briefly discussed.
Because the ultimate purpose of new medical knowledge is to achieve improved health outcomes, physicians need to possess and use this knowledge in their practice. The authors introduced enhanced education and individualized feedback to reduce postoperative nausea and vomiting (PONV). The primary objective was to increase anesthesiologists' use of preventive measures to reduce PONV, and the secondary objective was to determine whether patient outcomes were improved.
After obtaining hospital ethics committee approval, the effect of education and feedback on anesthesiologist performance and the rate of PONV in major surgery elective inpatients during a 2-yr period was assessed. After baseline data collection (6 months), anesthesiologists at the study hospital received enhanced education (8 months) and individualized feedback (10 months). Parallel data collection was performed at a control hospital at which practice was continued as usual. The education promoted preventive measures (antiemetic premedication, nasogastric tubes, droperidol, metoclopramide). Individualized feedback provided the number of patients receiving promoted measures and the rate of PONV. The mean percentage of anesthesiologists' patients receiving at least one promoted measure and the rate of PONV were compared with baseline levels.
At the study hospital, there was a significant increase in the mean percentage of the anesthesiologists' female patients receiving a preventive measure as well as a significant increase in the use of droperidol > or = 1 mg (P < 0.05) for all patients. The use of other promoted measures was unaffected. Absolute rates of PONV were unaffected at the study hospital until the post-feedback period (decrease of 8.8% between baseline and post-feedback (P = 0.015)).
It was demonstrated that enhanced education and individualized feedback can change anesthesiologists' practice patterns. The actual benefit to patients from use of preventive measures was limited when used in the everyday clinical situation. Therefore, only modest decreases in PONV were achieved, despite the use of preventive measures.
EXCERPT For almost 150 years healthcare workers have been taught that cross‐infections are transmissible but not contagious and that the most effective way to prevent these cross‐infections is to wash their hands before and after every patient contact.1,2 But, they don’t do it. They don’t merely not do it every time, they don’t do it most of the time and sometimes not even when it might be most expected, as when caring for an intensive care unit (ICU) or emergency room patient.3,4 A brief observation in almost any clinic or hospital will confirm these lapses. Why don’t physicians and nurses follow this most basic care practice?