SEARCH · PubMed Health

Results for “Guidelines”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,351 records · Page 75Linked to original sources

PubMed2005

An evaluation of compliance with practice guidelines on interhospital trauma transfer.

STUDY OBJECTIVES: To prospectively evaluate compliance with current interhospital trauma transfer guidelines in South West Sydney, before and after an implementation programme was instituted. METHODS: A scoring system was developed to assess compliance with the 11 main components of the guideline. Baseline compliance was measured during an initial 3-month period (pre), followed by an implementation programme to alert staff at referring hospitals to the presence of the guidelines. Following this, compliance was again measured over 3 months (post). RESULTS: Twenty-two patients were transferred during the pre-implementation phase and 35 patients during the post-phase. Overall compliance with the guidelines increased from 62 to 67%. Mean pre-hospital compliance rose from 75 to 95%, and referring hospital compliance rose from 59 to 63%. While there was an improvement in compliance with the use of the dedicated trauma hotline (86-97%), the use of a transfer checklist (41-53%), and appropriateness of transfer (95-100%), none of these reached statistical significance. CONCLUSION: Practice guidelines have been developed to optimise the process of interhospital trauma transfers. An implementation programme met with limited success in improving compliance with the guidelines. Further work is needed to ensure awareness of these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome.

Adult↗

PubMed2002

Evidence-based practice guidelines--one way to enhance clinical practice.

Abdominoplasty and liposuction guidelines are just two of the guidelines that can be accessed and used to enhance patient care. Guidelines also can be used to increase your knowledge about many other health care topics. The NGC has approved guidelines for managing chronic pain, as well as guidelines on chronic diseases (e.g., diabetes mellitus, hypertension, chronic obstructive pulmonary disease). Many patients have chronic diseases, and you or your family members also may be affected by chronic disorders. These guidelines provide you with a quick overview of evidence-based treatment protocols. These guidelines are not a panacea for evidence-based practice, but using them is one way that perioperative nurses can enhance their clinical skills. Though not everyone has personal Internet access, most health care facilities do or can make access a reality. Other options include medical or public libraries. Then one simply has to access the NGC web site and join other professionals in improving the quality and timeliness of patient care.

Adult↗

PubMed2003

Development of an implementation strategy for physiotherapy guidelines on low back pain.

In the Netherlands, clinical practice physiotherapy guidelines are mainly implemented by using passive implementation strategies. It is well known that these strategies are not effective in establishing changes in behaviour of health care professionals. Therefore, a new implementation strategy was developed for the physiotherapy guidelines on low back pain. This paper describes the method for the design of this strategy. A survey was conducted of 100 physiotherapy practices to identify perceived barriers to implementation of the guidelines and the most important discrepancies between current practice and recommendations of the guidelines. The strategy was further developed using a model for changing professionals' behaviour and systematic reviews on the effectiveness of implementation interventions. The most frequently reported barriers for implementation of the guidelines are related to a lack of knowledge or skills of physiotherapists. The most frequently reported discrepancies between physiotherapy practice and guidelines recommendations were related to the focus of the diagnostic process on impairments, the common use of passive physiotherapeutic interventions, the frequent use of a pain-contingent approach, and the expectations of the patient. The new implementation strategy consisted of multiple interventions, namely education, discussion, role-playing, feedback and reminders. The strategy addressed perceived barriers and discrepancies between current practice and the recommendations of the guidelines.

Adult↗

PubMed2004

[Lung diseases in the elderly. Assessment of guidelines for the probabilistic prescription of antibiotics in a department of geriatric care].

OBJECTIVE: We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure. METHOD: The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients>65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality. RESULTS: Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated. CONCLUSION: The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

Aged↗

PubMed2005

[Local guidelines and quality of antibiotic treatment in urinary tract infections: a clinical audit in two departments of a university hospital].

AIM: To assess the effect of local guidelines implemented at the Nantes University Hospital regarding antibiotic therapy for urinary tract infections. DESIGN: Before/after study of one medical ward and one urologic surgery ward. Quality was measured by two principal criteria: compliance with guidelines and medical justification in the specific clinical situation. Both criteria considered simultaneously the choice of drug, dose and duration of treatment. Deviations from the guidelines were described. RESULTS: 1086 UTI cases were identified over two 12-month periods, before and after the dissemination of guidelines (for prostatitis, pyelonephritis, indwelling catheter-associated UTIs, and other undefined UTIs). The guidelines were applicable in 313 (30%) cases. Overall, after implementation of the guidelines, the percentage of justified prescriptions did not change significantly (41.8% compared with 38.7%, p=0.299), but the percentage of correct (conforming) prescriptions fell (from 30.4% to 15.7%, p=0.0022). The percentages of correct and justified prescriptions differed in the medical (respectively 45.0% and 46.6%,) and surgical units (13.1% and 36.5%). CONCLUSIONS: Issuing guidelines does not necessarily improve the quality of antibiotic therapy for UTIs in hospitals.

Anti-Bacterial Agents↗

PubMed2000

Lessons from experienced guideline implementers: attend to many factors and use multiple strategies.

BACKGROUND: Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used. METHODS: In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information. RESULTS: Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment. DISCUSSION: Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.

Delphi Technique↗

PubMed1998

Cross-sectional analysis of the relationship between national guideline recommended asthma drug therapy and emergency/hospital use within a managed care population.

BACKGROUND: Nationally recognized clinical guidelines provide recommended therapies for the treatment of asthma. Research demonstrating the impact of guideline recommended drug therapy on utilization [emergency department (ED) and hospitalizations] is beneficial when considering these guidelines for managing asthmatics within a managed care setting. OBJECTIVE: The purpose is to determine the relationship between ED/hospital claims and selected asthma drug therapies as recommended by the National Asthma Education Program Expert Panel and the National Heart, Lung, and Blood Institute/ World Health Organization Workshop. METHODS: The analysis is a retrospective, cross-sectional study within a managed care organization (MCO), serving 359,464 patients in the state of Florida. Asthma patients from all lines of business (Medicaid, Medicare, commercial) were stratified into subgroups based on the type of drug therapy utilized. Members included were those identified as having at least one prescription filled for an asthma medication between January 1, 1995 and June 30, 1995 and at least six consecutive months of enrollment within the health plan. Pharmacy and medical claims data were collected over a 1.5-year study period (January 1, 1995 through June 30, 1996) to assure follow-up on utilization was at a minimum 6 months and maximum 1.5 years. Outcomes were measured based on patient utilization of tertiary medical services (asthma-related ED and hospital visits) through claims. RESULTS: Total membership within the Florida MCO, reflected 359,464 members of whom 5.2% were identified as asthmatic. The asthma members were reviewed based on pharmacy claims data, identifying 26.2% of the members utilizing inhaled corticosteroids concomitantly with a short-acting beta2-agonist. Upon further review of this subset, 85% were utilizing short-acting beta2-agonists in quantities at or below recommended dosages. Patients not utilizing the beta2-agonist therapy according to the recommended dosing guidelines had a significantly higher incidence (P = .001) of ED and hospital use. The remaining asthma population was reviewed, identifying 33.2% of the members utilizing short-acting beta2-agonists alone. This subset revealed 97.6% were utilizing therapy according to the beta2-agonist dosing guidelines. Patients not utilizing the beta2-agonist therapy according to dosing guidelines had a significantly higher incidence (P = .016) of ED and hospital use. CONCLUSION: Assessment of asthma therapy in a managed care population demonstrates that there is a lower proportionate use of the ED and hospital in those patients treated in accordance to the asthma guideline recommendations.

Administration, Inhalation↗

PubMed2000

Improving clinical practice guidelines for the 21st century. Attitudinal barriers and not technology are the main challenges.

Through the use of three scenarios, this paper presents the challenges for clinical practice guidelines in the 21st century. Such challenges relate to technological developments to improve the efficiency and pace of the development process, to ensure that clinical practice guidelines are kept up to date, and to facilitate implementation of guidelines in the clinical setting. To improve and ensure the validity of the content of clinical practice guidelines, we need to address the important problem of publication bias, for which researchers, granting agencies, industry, and journal editors share responsibility. This means insisting on registration of trials at their inception, and incentives backed up by rules for funding and peer review publication that would promote behaviors to avoid publication bias. The more difficult challenges for clinical practice guidelines relate to what are referred to as attitudinal factors. To achieve optimal efficiencies in development and maintenance of clinical practice guidelines, we need to promote cooperation among various information resource providers internationally and to stress partnership over leadership. Finally, there need to be reconciliation of the different stakeholder perspectives of the value and purpose of clinical practice guidelines so that they are used appropriately as aids to decision making and are not abused as tools for controlling clinical practice.

Decision Support Systems, Clinical↗

PubMed2006

Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children.

OBJECTIVES: Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland. METHODS: A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients. RESULTS: The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy. CONCLUSIONS: Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.

Acute Disease↗

PubMed2003

Implementation of guidelines for seasonal allergic rhinitis: a randomized controlled trial.

BACKGROUND: Allergic rhinitis is a common disease altering quality of life. Its treatment is well established and guidelines have been proposed. However, their efficacy has never been tested. The aim of the study was to validate the guidelines of the International Consensus on Rhinitis in the treatment of seasonal allergic rhinitis. METHODS: A multicenter, multinational, open label, parallel, randomized study compared two therapeutic strategies in seasonal allergic rhinitis during a 3-week treatment. General practitioners were randomized into two groups. In the first group of 224 patients, doctors followed guidelines from the International Consensus on Rhinitis. Depending on the severity of nasal and ocular symptoms defined using visual analogue scales, patients received ebastine (an oral antihistamine), triamcinolone acetonide (a topical corticosteroid) and/or ophthalmic nedocromil sodium (a topical ocular cromone). In the second group of 241 patients, general practitioners had a free choice of treatment. The primary efficacy end points were quality of life measured using the standardized rhinoconjunctivitis quality of life questionnaire (RQLQ) and the symptom-medication scores assessed daily with an electronic dairy system. RESULTS: Adjusted mean total symptom scores over 21 days were 4.93 in the guidelines strategy group compared with 7.48 in the free-choice treatment group (P = 0.0001). Mean total scores in the RQLQ decreased by 2.19 in the guidelines group compared with a decrease of 1.79 in the free-choice treatment group (P = 0.0001). At 21 days, the least square mean difference in improvement in overall scores for RQLQ in the guidelines group compared with the free-choice treatment group was 0.53, which was greater than the minimal important difference. CONCLUSIONS: Patients with seasonal allergic rhinitis often present severe symptoms which are not well recognized or controlled by physicians using their own criteria of severity and treatment. Using a simple method for the evaluation of the severity and a simple therapeutic scheme based on International Guidelines, patients with seasonal allergic rhinitis presented a significant improvement by comparison with those receiving a non-standardized treatment.

Administration, Intranasal↗

PubMed2003

Adherence to pressure ulcer prevention guidelines: implications for nursing home quality.

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs. DESIGN: Review of NH medical records. SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs. PARTICIPANTS: A nested random sample of 834 residents free of PU on admission. MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical. RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P <.001) and from 24% to 75% across the six key recommendations (P <.001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated. CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.

Adult↗

PubMed2003

Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence.

We have updated guidelines for screening for colorectal cancer. The original guidelines were prepared by a panel convened by the U.S. Agency for Health Care Policy and Research and published in 1997 under the sponsorship of a consortium of gastroenterology societies. Since then, much has changed, both in the research rature and in the clinical context. The present report summarizes new developments in this field and suggests how they should change practice. As with the previous version, these guidelines offer screening options and encourage the physician and patient to decide together which is the best approach for them. The guidelines also take into account not only the effectiveness of screening but also the risks, inconvenience, and cost of the various approaches. These guidelines differ from those published in 1997 in several ways: we recommend against rehydrating fecal occult blood tests; the screening interval for double contrast barium enema has been shortened to 5 years; colonoscopy is the preferred test for the diagnostic investigation of patients with findings on screening and for screening patients with a family history of hereditary nonpolyposis colorectal cancer; recommendations for people with a family history of colorectal cancer make greater use of risk stratification; and guidelines for genetic testing are included. Guidelines for surveillance are also included. Follow-up of postpolypectomy patients relies now on colonoscopy, and the first follow-up examination has been lengthened from 3 to 5 years for low-risk patients. If this were adopted nationally, surveillance resources could be shifted to screening and diagnosis. Promising new screening tests (virtual colonoscopy and tests for altered DNA in stool) are in development but are not yet ready for use outside of research studies. Despite a consensus among expert groups on the effectiveness of screening for colorectal cancer, screening rates remain low. Improvement depends on changes in patients' attitudes, physicians' behaviors, insurance coverage, and the surveillance and reminder systems necessary to support screening programs.

Colorectal Neoplasms↗

PubMed2003

Open-access endoscopy: are age-based guidelines justified? An audit of experience of 1000 open-access endoscopies at a district general hospital.

BACKGROUND AND STUDY AIMS: Open-access endoscopy has been developed to meet the increasing demand for endoscopy, and guidelines have been produced for selecting suitable patients. This study was designed to assess the appropriateness of these guidelines in patients referred to open-access endoscopy services at a district general hospital. PATIENTS AND METHODS: A series of 1000 consecutive patients referred for open-access endoscopy was audited. The waiting time was 18 weeks and patients continued to take any acid-suppressing medication prescribed by their general practitioner. The endoscopy findings were compared in those who met and did not meet currently accepted guidelines. In addition the outcome for all patients in whom gastro-oesophageal malignancy was detected was reviewed. RESULTS: 301 patients (30.1 %) did not meet accepted guidelines for open-access endoscopy. No cases of malignancy would have been missed if the guidelines had been implemented. Gastro-oesophageal malignancy was detected in 17 patients, all of whom died. When malignancy was excluded, there were no statistically significant differences between the detection rates for pathology in the two groups. The commonest finding, in 32.3 % of patients, was of a normal endoscopic appearance. CONCLUSIONS: If current guidelines are applied, all cases of malignancy may be picked up, but identification of patients with curable disease is poor. Use of the guidelines did not select patients with other upper gastrointestinal disease, although many patients were receiving acid-suppression therapy at the time of their endoscopy. Implementation of test-and-treat strategies would result in a significant reduction in the workload of open-access endoscopy.

Adult↗

PubMed2006

[Guideline conformance for outpatient management of COPD in Germany].

BACKGROUND AND OBJECTIVE: Primary care physicians (PCPs) are the ones mainly responsible for the initial diagnosis and outpatient care of patients with COPD. The aim of the present survey was to investigate their initial management of COPD in Germany based on current guidelines and to identify any deviations. METHODS: A prospective cross-sectional survey was conducted as a multiple-choice questionnaire sent out to 1836 PCPs in seven Federal States of Germany (one large town and surrounding country in each). The product-neutral questions focused on the key aspects of current national and international (GLOBAL) COPD guidelines. RESULTS: 486 physicians participated in the study (response rate 26.5%). 66.5% of the physicians used the German COPD guidelines, 20.8% used GOLD guidelines, and only 11.7% observed no guidelines. The physicians were aware of the epidemiological and public health significance of COPD. 76.5% saw spirometry as the diagnostic standard: it was available in 90.1% of the practices. However, only 60-65% were able to cite the correct spirometric criteria for classifying severity of the disease. Educational measures to help patients quit smoking and the teaching and monitoring of patients' inhalation technique were inadequately implemented. The two most important therapeutic goals cited were to improve quality of life (69.1%) and prevent exacerbations (53.1%). Except for the criteria for the use of steroids and the implementation of pulmonary rehabilitation measures, treatment of COPD based on severity class was largely in compliance with the guidelines. However, a significant percentage of the physicians incorrectly assessed the evidence-based clinical benefits of various therapeutic measures. CONCLUSION: The study shows that, despite the high regard in which COPD guidelines are held, deficiencies exist with regard to the diagnosis and treatment of COPD and the practical implementation of educational measures.

Adult↗

PubMed2001

Utilization of incontinence clinical practice guidelines.

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.

Adult↗

PubMed2002

Are dyspepsia management guidelines coherent with primary care practice?

BACKGROUND: Spontaneous physician behaviour can affect guideline applicability, implementation strategies and application costs, particularly in relation to widespread pathologies chiefly managed by general practitioners (GPs). Of the array of dyspepsia management guidelines, the closest to general practice, partly owing to proposing committee composition, are the European Society for Primary Care Gastroenterology (ESPCG) guidelines. METHODS: To evaluate variability in dyspepsia management among GPs in Padua and divergence in spontaneous prescriptive behaviour from the ESPCG dyspepsia guideline, we prospectively studied the behaviour of 39 GPs over a 3-month period of outpatient activity, through questionnaires on each consultation. Test-group representativeness was preliminarily defined in terms of antisecretory drug expenditure. RESULTS: 1790 forms on dyspepsia-related consultations were studied in a population of 51,193 registered patients; 1264 patients with a history of dyspeptic pathology consulted their GP (19% duodenal ulcer (DU), 9% gastric ulcer (GU), 54% gastro-oesophageal reflux disease (GERD), 32% non-ulcer dyspepsia (NUD), 1% cholelithiasis), while 526 patients presented with symptoms of dyspepsia with no previous gastroscopy (EGDS) (42% were aged <45 years), of whom 42% had twice consulted their GP. Empirical management by prescription of symptomatic drugs was the most common procedure in DU (33%), GU (73%) and NUD (74%) relapses. Helicobacter pylori eradication therapy was prescribed in only 2% of patients with a history of organic or functional dyspepsia. 145 patients with uninvestigated dyspepsia were referred for second-level endoscopy and 43 for H. pylori testing. Forty-four percent of endoscopies prescribed for uninvestigated patients did not comply with the ESPCG guideline; full compliance would have determined a 105% rise in endoscopies. Prescriptive variability between GPs was high (based on the Goodman-Kruskal (0.41, P < 0.001) and Cramer tests (V = 0.51, P < 0.005)) and agreement between observed and expected prescriptions according to ESPCG criteria was as low as V = 0.11. On the basis of the most frequently observed behaviours, we developed three options of the ESPCG guideline and compared them to spontaneous prescriptions. CONCLUSIONS: Highest compliance emerged where the clinical approach for all patients with uninvestigated dyspepsia was symptomatic therapy at first presentation followed by a different attitude at second presentation, setting a higher cut-off age than in the guideline (which in our case proved, on mathematical calculation, to be 55 years).

Adult↗

PubMed2005

Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management.

In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by (1) describing the process by which the exposure might be evaluated, (2) identifying the key decision elements in managing the case, (3) providing clear and practical recommendations that reflect the current state of knowledge, and (4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. (1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). (2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). (3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). (4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). (5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). (6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). (7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). (8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). (9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). (10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). (11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).

Adult↗

PubMed2004

Managing HIV-infected patients on antiretroviral therapy in Rio de Janeiro, Brazil: do providers follow national guidelines?

The objective of the paper was to compare provider practices in prescribing antiretroviral (ARV) drug regimens and use of laboratory monitoring at three health care facilities and to determine whether Brazilian national guidelines are being followed. A retrospective, cross-sectional survey was employed. We selected a sequential sample of patients on ARV therapy who registered at three health care facilities in Rio de Janeiro, Brazil, during 2001. We abstracted 2001 patient visit data from medical records using standardized data forms. Provider practice was compared to the 2000 Brazil national guidelines for ARV use. Providers who prescribed recommended or acceptable regimens were considered as having conformed to guidelines. Only 2% of patient records (N=984) reported use of inappropriate regimens as defined by the Brazil 2000 national ARV guidelines. Forty-nine per cent of patients at the Evandro Chagas hospital, 17% of those at Hospital Geral, and 57% of those at Centro da Saude were prescribed recommended therapies. Twenty per cent of patients seen at the public district hospital received dual ARV therapy, an acceptable regimen at the time. Although the national guidelines do not provide recommendations on laboratory monitoring, during the 1 year study period a majority of patients had at least one CD4+ cell count (92%) or viral load measurement (86%). Providers' practices in prescribing ARV regimens at these Rio de Janeiro facilities conform to national guidelines. Physicians would benefit from Brazilian ARV guidelines which incorporate the international consensus on the frequency of laboratory monitoring appropriate for patients in resource-constrained settings.

Adolescent↗