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PubMed2003

Evaluation of a rape protocol: a five year follow-up with nurse managers.

PURPOSE: To evaluate the use and effectiveness of a protocol developed for emergency nurses and other medical personnel to use with survivors of sexual assault. The Ohio Department of Health (ODH) Protocol for the Treatment of Adult Sexual Assault Survivors was developed by a multi-disciplinary team in 1991-92 as a written guide to provide comprehensive, standardized, non-judgmental, and equitable treatment for survivors. In 1993, this 118-page manual was sent to all Ohio hospitals. In 1994, a follow-up video and training guide were also delivered. In 1997, Victims Rights Advocacy, a non-profit agency in Ohio, and the Center for Social Work Research at The University of Texas at Austin collaboratively conducted an evaluation of the utilization and effectiveness of this protocol at Ohio hospitals. DATA SOURCES: Emergency departments at Ohio hospitals were asked to complete a mailed survey regarding their policies and procedures for treating sexual assault patients. Telephone calls were made to the hospitals that did not return a survey, and site visits were conducted at 20 hospitals in diverse areas of Ohio. CONCLUSIONS: Overall, respondents concurred that hospitals can benefit from using a standardized protocol, such as the ODH Protocol, for treating victims of sexual assault. Survey participants also indicated that training is needed on several topics, especially testifying in court, cultural awareness, and the needs of special populations, such as male, gay, lesbian, and bisexual survivors. In addition, findings indicate that survivors need more follow-up services, and written information about these services should be provided to them. IMPLICATIONS FOR PRACTICE: Nurse practitioners can improve the treatment of sexual assault survivors in their communities through a variety of actions, such as gathering information about available protocols and training opportunities for personnel, and becoming familiar with resources that can help victims.

Adolescent↗

PubMed2001

Reference dosimetry in clinical high-energy photon beams: comparison of the AAPM TG-51 and AAPM TG-21 dosimetry protocols.

Task Group 51 (TG-51) of the Radiation Therapy Committee of the American Association of Physicists in Medicine (AAPM) has recently developed a new protocol for the calibration of high-energy photon and electron beams used in radiation therapy. The formalism and the dosimetry procedures recommended in this protocol are based on the use of an ionization chamber calibrated in terms of absorbed dose-to-water in a standards laboratory's 60Co gamma ray beam. This is different from the recommendations given in the AAPM TG-21 protocol, which are based on an exposure calibration factor of an ionization chamber in a 60Co beam. The purpose of this work is to compare the determination of absorbed dose-to-water in reference conditions in high-energy photon beams following the recommendations given in the two dosimetry protocols. This is realized by performing calibrations of photon beams with nominal accelerating potential of 6, 18 and 25 MV, generated by an Elekta MLCi and SL25 series linear accelerator. Two widely used Farmer-type ionization chambers having different composition, PTW 30001 (PMMA wall) and NE 2571 (graphite wall), were used for this study. Ratios of AAPM TG-51 to AAPM TG-21 doses to water are found to be 1.008, 1.007 and 1.009 at 6, 18 and 25 MV, respectively when the PTW chamber is used. The corresponding results for the NE chamber are 1.009, 1.010 and 1.013. The uncertainties for the ratios of the absorbed dose determined by the two protocols are estimated to be about 1.5%. A detailed analysis of the reasons for the discrepancies is made which includes comparing the formalisms, correction factors and quantities in the two protocols, as well as the influence of the implementation of the different standards for chamber calibration. The latter has been found to have a considerable influence on the differences in clinical dosimetry, even larger than the adoption of the new data and recommended procedures, as most intrinsic differences cancel out due to the adoption of the new formalism.

Biophysical Phenomena↗

PubMed2004

A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation.

Weaning protocols can improve outcomes, but their efficacy may vary with patient and staff characteristics. In this prospective, controlled trial, we compared protocol-based weaning to usual, physician-directed weaning in a closed medical intensive care unit (ICU) with high physician staffing levels and structured, system-based rounds. Adult patients requiring mechanical ventilation for more than 24 hours were assigned to usual care (UC) or protocol weaning based on their hospital identification number. Patients assigned to UC (n=145) were managed at their physicians' discretion. Patients assigned to protocol (n=154) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention. There were no significant baseline differences in patient characteristics between groups. The proportion of patients (protocol vs. UC) who successfully discontinued mechanical ventilation (74.7% vs. 75.2%, p=0.92), duration of mechanical ventilation (median [interquartile range]: 60.4 hours [28.6-167.0 hours] vs. 68.0 hours [27.1-169.3 hours], p=0.61), ICU (25.3% vs. 28.3%) and hospital mortality (36.4% vs. 33.1%), ICU length of stay (115 vs. 146 hours), and rates of reinstituting mechanical ventilation (10.3% vs. 9.0%) was similar. We conclude that protocol-directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds.

Adult↗

PubMed1991

Treatment protocols in child and adolescent day treatment.

Twenty treatment protocols in a day treatment program for children and adolescents have been developed by multidisciplinary groups based on a review of 200 patients. The protocols classify patients according to symptom clusters and provide standardized treatment plans for each classification. Each protocol contains a definition of the symptom cluster, a list of presenting problems, a list of other protocols to consider, admission guidelines, treatment options, and discharge criteria. The authors describe the developmental process for the protocols and present a clinical case example to illustrate their use. The application of treatment protocols in research, quality assurance, and teaching is briefly discussed.

Adolescent↗

PubMed2001

Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol.

BACKGROUND: Evidence from recent literature shows that protocol-directed extubation is a useful approach to liberate patients from mechanical ventilation (MV). However, research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units (ICUs). We conducted the present study to determine whether such an evidence-based strategy can be implemented safely and effectively using a multidisciplinary team (MDT) approach. METHOD: We designed a MDT-driven extubation protocol. Multiple meetings were held to encourage constructive criticism of the design by attending physicians, nurses and respiratory care practitioners (RCPs), in order to define a protocol that was evidence based and acceptable to all clinical staff involved in the process of extubation. It was subsequently implemented and evaluated in our medical/ surgical ICU. Outcomes included response of the MDT to the initiative, duration of MV and stay in the ICU, as well as reintubation rate. RESULTS: The MDT responded favourably to the design and implementation of this MDT-driven extubation protocol, because it provided greater autonomy to the staff. Outcomes reported in the literature and in the historical control group were compared with those in the protocol group, and indicated similar durations of MV and ICU stay, as well as reintubation rates. No adverse events were documented. CONCLUSION: An MDT approach to protocol-directed extubation can be implemented safely and effectively in a multidisciplinary ICU. Such an effort is viewed favourably by the entire team and is useful in enhancing team building.

Adult↗

PubMed2004

The Robinson Protocol: a treadmill anaerobic performance test.

The current investigation was designed to further examine the reliability of the Robinson protocol, which is a run-to-exhaustion treadmill test. Robinson (10) originally examined this protocol with 5 subjects. The significance of the initial exploratory study was the impetus for expanding the study to examine the reliability of the protocol with a larger sample. Fifteen male subjects participated in 3 trial runs on the treadmill. The first trial was a modified McConnell (7) test to determine the aerobic capacity of each subject. The second and third trials were identical Robinson protocols (10). The first trial run mean, in seconds (262.04 +/- 74.50), was not significantly different from the second trial run mean (257.30 +/- 72.65), p = 0.526 (2 tailed). As expected, trial 1 and trial 2 were highly correlated (intraclass) (r = 0.927, p < 0.001). These results provide additional support for the hypothesis that the Robinson protocol with a greater subject pool is a reliable protocol that can be used in research studies interested in examining various physiological interventions or anaerobic training.

Adolescent↗

PubMed1997

A standard protocol for blood pressure measurement in the newborn.

OBJECTIVES: Improvements in neonatal care have resulted in increasing survival of extremely premature infants whose hospital course often runs into weeks or months. Some interventions during the acute care of these neonates, such as umbilical catheterization and use of steroids, not infrequently result in elevation of blood pressure (BP). It is, therefore, essential that these infants be monitored accurately for possible hypertension during their convalescence. Unfortunately, normative data on BP in this population are scant and comparison of data from various studies is hampered by methodologic differences in design. Studies in adults address the necessity for a restful state, adopting a comfortable position, and attempts to reduce the startle response to initial cuff inflation. Studies in the newborn using the oscillometric technique have not addressed these concerns. A standard BP measurement protocol was studied to determine the effect of ensuring a restful state, startle response to cuff inflation, and infant position on BP in clinically stable low birth weight infants after the first week of life. STUDY DESIGN: The Dianamap oscillometer was used to measure BP in infants with a birth weight <2500 g between 7 and 42 days postnatal age. Each infant was studied only once when they were clinically stable. BP was measured in two positions, prone and supine, in random order. Infants were studied at least 11/2 hours after their last feeding or medical intervention. An appropriate sized cuff was applied to the right upper arm and the infant was positioned according to randomization. The infant was then left undisturbed for at least 15 minutes or until the infant was sleeping or in a quiet awake state. Three successive BP recordings were taken at 2-minute intervals. The infant's position was then reversed and another 15 minutes of quiet time was allowed. Thereafter, a second set of three successive BP recordings were obtained. The most recent routine nursing BP measurement was also recorded. Data were analyzed using analysis of variance and are presented as means and standard errors of the mean. RESULTS: Sixty-four infants were studied. Birth weights ranged from 901 to 2423 g and gestational ages from 26 to 37 weeks. Overall, mean BP was significantly lower in the prone than supine positions (45.7 +/- 0.7 vs 47.8 +/- 0.8 mm Hg, P < .002). In either position, the first measurement was significantly higher than the third (average difference was 3 mm Hg, P < .003). In general, the relationships among position and order of measurement were similar for systolic and diastolic BP. Mean BPs obtained by routine nurse measurements were significantly higher than those in either position using our standard protocol (54.4 vs 47.0 or 49.1 mm Hg, P < .003). Moreover, the routine nurse measurements varied more widely than did those obtained using the standard protocol. The standard deviation for the routine mean BP measurements by nurses was 11.4 compared with 6.8 and 8.2 for the first measurements in the prone and supine positions, respectively, with the standard protocol. The mean BP measurements made in the supine position (the highest measurements obtained) using the standard protocol were also significantly lower than published values: 57 of 64 measurements were less than the average mean BP for age described by Tan (J Pediatr. 1988; 112:266-270). CONCLUSION: The statistically significant difference between the prone and supine position and among successive measurements in each position are not clinically relevant. The clinically significant differences between measurements obtained with this standard protocol and routine nursing measurements or published data are the result of ensuring a restful state after cuff application. We believe that measurements thus obtained are more representative of true resting BPs in these infants. (ABSTRACT TRUNCATED)

Analysis of Variance↗

PubMed2005

Antibiotic prophylaxis in orthopedic surgeries: the results of an implemented protocol.

Though the basic principles of antibiotic prophylaxis have been well established, there is still considerable incorrect usage, including how much is prescribed and especially in the duration of treatment, which is generally superior to what is indicated. The adequate use of these drugs contributes towards decreasing the time of internment of the patient, prevents surgical site infection (SSI), decreasing the development of resistant microorganisms, and towards reduced costs for the hospital pharmacy. A protocol for the use of antibiotic prophylaxis in the Orthopedics and Traumatology Service of the Hospital do Servidor Público Estadual de São Paulo was developed. The objectives of the study were to promote rational antibiotic surgical prophylaxis, through the implantation of a protocol for the use of these drugs in a surgical unit, with the direct contribution of a druggist in collaboration with the Infection Control Committee, to evaluate the adhesion of the health team to the protocol during three distinct periods (daily pre-protocol, early post-protocol and late post-protocol) and to define the consumption of antimicrobials used, measured as daily defined dose.

Antibiotic Prophylaxis↗

PubMed2004

Achieving target antifactor Xa activity with a heparin protocol based on sex, age, height, and weight.

STUDY OBJECTIVES: To develop and validate an improved unfractionated heparin (UFH) dosage protocol, using antifactor Xa levels as the outcome variable. DESIGN: Prospective case series. SETTING: A 625-bed, adults-only private, tertiary care teaching hospital. PATIENTS: Three hundred seventy-two patients receiving UFH for eight different indications were in the protocol derivation group. One hundred ninety-seven patients were in the final validation group. Intervention. Variables that predicted successful UFH treatment were determined by analysis of variance and regression. MEASUREMENTS AND MAIN RESULTS: Sex, age, height, weight, UFH dosage, and antifactor Xa levels were variables. A regression model using sex, age, height, and weight was superior to a weight-only model in predicting UFH dosage. Target-range antifactor Xa levels were achieved with the new protocol in 122 (87%) of 140 patients within 24 hours of start of therapy. CONCLUSION: A UFH dosage protocol based on patient sex, age, height, and weight produced improved initial target antifactor Xa levels compared with a weight-based protocol. The protocol is computerized and easy to apply.

Adolescent↗

PubMedDate not supplied

Dexamethasone, melphalan, actinomycin D, cytosine arabinoside (DMAC) protocol for dogs with relapsed lymphoma.

BACKGROUND: In general, treatment of relapsed lymphoma is associated with a lower probability of response and shorter duration of remission. The purpose of this study was to evaluate the efficacy of the combination chemotherapy protocol DMAC (dexamethasone, melphalan, actinomycin D, and cytosine arabinoside) for reinduction of remission in dogs with relapsed lymphoma. HYPOTHESIS: That DMAC would be an effective reinduction protocol for dogs with relapsed lymphoma. ANIMALS: Fifty-four dogs. RESULTS: Seventy-two percent of the dogs achieved remission (44% complete remission [CR] and 28% partial remission [PR]), 11% had stable disease (SD), and 17% had progressive disease (PD). The median remission duration was 61 days (range, 2-467+ days). The median remission durations for dogs with CR, PR, and SD were 112, 44, and 27 days, respectively. Factors that affected the response rate were previous treatment with doxorubicin and an inability to achieve remission with the previous protocol. Thrombocytopenia occurred in 56% of the dogs (grade 1 in 3 dogs, grade 2 in 6 dogs, grade 3 in 7 dogs, and grade 4 in 7 dogs) and neutropenia in 17% of the dogs (grade 2 in 1 dog, grade 3 in 2 dogs, and grade 4 in 4 dogs). Gastrointestinal toxicosis occurred in 22% of the dogs (grades 1 in 5 dogs, grade 2 in 3 dogs, and grade 3 in 1 dog). CONCLUSIONS AND CLINICAL IMPORTANCE: The DMAC protocol is an effective rescue protocol for dogs with relapsed multicentric lymphoma. Although thrombocytopenia is a common manifestation of toxicity, in general, the protocol is well tolerated.

Animals↗

PubMed2005

Insulin infusion protocol for critical care units.

PURPOSE: An insulin infusion protocol for critical care units is described. SUMMARY: Evidence that aggressive glycemic control improves outcomes led physicians, nurses, dietitians, and pharmacists at a trauma center to develop an insulin infusion protocol. Before the protocol, elevated blood glucose concentrations were often not treated until they reached 200 mg/dL or higher. Insulin infusions were underutilized and were often not started until capillary blood glucose concentrations were greater than 350 mg/dL for 12 or more hours. When orders for an insulin infusion were written, they did not include directions for dosage adjustment, and the goal blood glucose range varied. A preliminary protocol was drafted allowing adjustments in insulin administration to be based on changes in capillary blood glucose values since the previous blood glucose measurement. The protocol was presented to a multidisciplinary team and further refined. The targeted blood glucose concentration range was 80-130 mg/dL. After the targeted range was achieved for a patient, if the blood glucose level continued to decrease over three consecutive measurements, the infusion rate was decreased by 0.5 or 1 unit/hr, depending on the capillary blood glucose level. Data for the first 30 patients were collected from September 2003 to August 2004. It took 2-36 hours (mean, 12.6 hours) to bring the capillary blood glucose concentration to less than 130 mg/dL. Among 2,845 capillary blood glucose measurements, there were 15 cases of hypoglycemia (0.4%) requiring treatment with 50% dextrose injection. CONCLUSION: A multidisciplinary effort resulted in the development of an insulin infusion protocol for use in critical care units.

Clinical Protocols↗

PubMed1992

A protocol for aerosol therapy in acute hospitalized asthmatics.

The most important element in the treatment of acute hospitalized asthmatics is salbutamol administered via wet nebulization prescribed usually on a subjective evaluation of the patient's status. This study outlines a novel protocol that incorporates the FEV1 variable as the major objective parameter in a feedback loop. Data from patients admitted in the year prior to the initiation of the protocol (N = 348) were compared with similar data from patients hospitalized the year following institution of the protocol (N = 238). There were no withdrawals from the protocol due to adverse effects nor were there any deteriorations requiring ICU admission. A significant decrease in the length of hospitalization and the number of salbutamol prescriptions per hospitalization was observed after, relative to before, institution of the protocol (2.2 vs. 2.6 days; 2.3 vs. 3.8; p < .05, respectively). It is concluded that this protocol is safe and efficient, and may also be more efficacious than a nonstandardized approach for treating the hospitalized asthmatic child.

Acute Disease↗

PubMed2005

Development of a clinical protocol for home hospice care for Koreans.

As the Korean government's recognition of the importance of hospice service grows, the government has initiated a variety of hospice services in Korea. Each hospice organization has shown a significant difference in its health care delivery methods, constitution and care content. Developing a clinical protocol is essential for establishing standardized hospice services. A preliminary protocol was drawn up by examining the records of terminal patients (n=541) in a home hospice organization while elucidating the health problems as well as classifying them through the Home Health Care Classification (HHCC), and by reviewing the relevant nursing interventions and medical treatments in the literature concerning the clinical protocols. Korea's leading hospice specialty groups participated in four rounds of content validity verification processes in order to establish a protocol. A guideline was developed through a team approach, integrating the opinions of doctors, nurses, ministers, volunteers, patients' families, nutritionists and pharmacists. Eighteen health problems and a total of 223 interventions (173 major treatments and nursing interventions, and 50 optional interventions) were included in the final clinical protocol. This study is expected to contribute to the overall qualitative improvement of home hospice care and the subsequent shortening of documentation time. Evaluation tools and a regulatory feedback system need to be developed in order to maintain consistent evaluation procedures based on the continuous promotion and use of the protocol.

Adult↗

PubMed2004

Effect of an intensive glucose management protocol on the mortality of critically ill adult patients.

OBJECTIVE: To assess the effect of an intensive glucose management protocol in a heterogeneous population of critically ill adult patients. PATIENTS AND METHODS: This study consisted of 800 consecutive patients admitted after institution of the protocol (treatment group, between February 1, 2003, and January 10, 2004) and 800 patients admitted immediately preceding institution of the protocol (baseline group, between February 23, 2002, and January 31, 2003). The setting was a 14-bed medical-surgical intensive care unit (ICU) in a university-affiliated community teaching hospital. The protocol involved intensive monitoring and treatment to maintain plasma glucose values lower than 140 mg/dL. Continuous intravenous insulin was used if glucose values exceeded 200 mg/dL on 2 successive occasions. RESULTS: The 2 groups of patients were well matched, with similar age, sex, race, prevalence of diabetes mellitus, Acute Physiology and Chronic Health Evaluation II scores, and distribution of diagnoses. After institution of the protocol, the mean glucose value decreased from 152.3 to 130.7 mg/dL (P<.001), marked by a 56.3% reduction in the percentage of glucose values of 200 mg/dL or higher, without a significant change in hypoglycemia. The development of new renal insufficiency decreased 75% (P=-.03), and the number of patients undergoing transfusion of packed red blood cells decreased 18.7% (P=.04). Hospital mortality decreased 29.3% (P=.002), and length of stay in the ICU decreased 10.8% (P=.01). CONCLUSION: The protocol resulted in significantly improved glycemic control and was associated with decreased mortality, organ dysfunction, and length of stay in the ICU in a heterogeneous population of critically ill adult patients. These results support the adoption of this low-cost intervention as a standard of care for critically ill patients.

APACHE↗

PubMed2001

Symptom management in older primary care patients: feasibility of an experimental, written self-disclosure protocol.

BACKGROUND: Distress-driven symptoms are prevalent among older primary care patients and account for a large percentage of office visits and increased medical costs. An experimental written self-disclosure protocol has been shown to reduce symptoms and use of health care services in healthy adults. Written self-disclosure as a method for reducing symptoms has not been evaluated in the primary care setting. OBJECTIVE: To evaluate the feasibility of adapting an experimental written self-disclosure protocol for the primary care setting. DESIGN: Randomized, single-blind feasibility study. SETTING: University-based geriatric and internal medicine primary care clinics. PATIENTS: 45 patients 66 years of age or older without a psychiatric diagnosis. INTERVENTION: Three 20-minute writing sessions focusing on distressing experiences (in the intervention group) or health behaviors (in the control group). MEASUREMENTS: The feasibility outcomes were patient recruitment, protocol logistics, and patient and provider satisfaction. The clinical outcomes were somatic and distress symptoms, health care utilization, and associated costs. RESULTS: One third of patients screened were recruited; 96% of patients recruited completed the protocol. Clinic contact time was an average of 55 minutes per patient. Patients and providers reported high levels of satisfaction with the protocol. Reductions in symptoms were minimal for both groups. Use of outpatient services and associated costs decreased in both groups, but the reduction was twice as great in the treatment group as in the control group. CONCLUSIONS: Findings support the feasibility of implementing the protocol as a primary care intervention.

Aged↗

PubMed1991

Problems of protocol practice in Japan.

With progress in medical knowledge and in the technology of medical care, the contents of medical practice have become increasingly complicated year by year. The protocol practice (clinical algorithms or scheduled care) has been experimentally employed as one of medical-practice systems aimed at providing better medical care and maintaining its high standards. In the protocol practice the criteria for decision-making, which are clinically employed, are precisely made up in advance so that practice will be performed systematically. The WHO has recommended this protocol practice as a medical-care system appropriate for realizing clinical experiments. In recent years a number of clinical studies have been born from the protocol practice and, thus, it has been considered to be a formula for conducting clinical experiments tolerant of scientific criticism. The protocol practice, however, since it is difficult to conduct smoothly, has not yet been settled. This study aims at considering what we should do to make the protocol practice system settled through the observation of pitfalls in the course of its application.

Clinical Medicine↗

PubMedDate not supplied

The protocol solution: a mildly acidic commentary.

Protocols have captured the imagination of American's health care guru's. These self-proclaimed experts promise decreases in health care expenses of up to 25 percent if protocols for the appropriate use of expensive procedures are adopted throughout the country. With the establishment of several proprietary protocol companies and the push to develop national clinical guidelines, protocols have appeared on the health care scene with a vengeance. However, protocols will have dramatically different effects, depending on how and where they are implemented. This article will concentrate on the challenges of implementing protocols in a single health care institution, typically a hospital or a managed care institution.

Algorithms↗

PubMed1993

Patient protocols: commissioning, design and use.

The author begins by considering existing definitions of 'protocol' and related terms and later develops this into a discussion of how they work. Among other things, we learn from this article that methods of designing protocols have a significant influence on their implementation, creating a problem for organizations attempting to introduce protocols to promote uniform treatment. While the advantages and disadvantages of protocols are summarized, such a summary is to some extent unrevealing. It has to be appreciated that medicine is practised by social groups governed by informal arrangements which protocols may disturb. Furthermore, by making medical procedures explicit protocols may open up social and moral problems which have previously been concealed.

Attitude of Health Personnel↗