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PubMed2006

Evaluation of an oxygen protocol in long-term care.

OBJECTIVE: The purpose of this study was to determine the effect of protocol-directed recommendations for oxygen therapy implemented by respiratory therapists in skilled nursing facilities. We hypothesized that the use of an oxygen protocol would reduce the number of missing and incomplete orders and unnecessary oxygen use in skilled nursing facilities. METHODS: We studied patients who required oxygen therapy in 17 Ohio-based skilled nursing facilities. Respiratory therapists assessed the need for oxygen therapy. Recommendations for oxygen use and orders were made in accordance with an algorithm-based protocol and guidelines established by the Ohio Department of Health. Data were prospectively collected from January 1 through March 31, 2005. RESULTS: Of 346 eligible patients, 261 had complete data and comprised the study sample. The mean +/- SD age was 83 +/- 11.8 years, and 79% were male. Payer mix included Medicaid (46%), Medicare Part A (36%), private pay (11%), and hospice (7%). Orders for oxygen therapy were incomplete or missing in 18% of the population. A total of 1,175 billed days were saved, which corresponded to a cost savings of US dollars 6,768. CONCLUSIONS: Successful implementation of an oxygen protocol can improve compliance with accreditation agency requirements by reducing the number of missing and/or incomplete orders for oxygen therapy. Financial and patient outcomes can also be enhanced by discontinuing unnecessary oxygen use and initiating oxygen therapy when clinically needed.

Adult↗

PubMed2006

Case management protocol and declining blood lead concentrations among children.

INTRODUCTION: Blood lead concentrations among children aged 6 years and younger become a concern at 10 microg/dL (0.48 micromol/L) or higher. The authors' objective was to determine whether initial blood lead concentrations of 10-19 microg/dL (0.48-0.96 micromol/L) declined among children aged 3 years and younger and whether the magnitude of decline was associated with the case management protocol of the state or local childhood lead poisoning prevention program. METHODS: The authors analyzed childhood blood lead surveillance data from 1994 through 1995 and case management protocols from six states that reported the results of all blood lead tests. The study included 2109 children aged 2 years or younger who had a venous blood lead concentration of 10-19 microg/dL (0.48-0.96 micromol/L) and a follow-up venous blood lead test within 3 to 12 months. RESULTS: Overall, blood lead concentrations increased by 0.25 microg/dL (0.01 micromol/L) between the time of the initial elevated blood lead test and the follow-up test, but concentrations declined by 1.96 microg/dL (0.09 micromol/L) among children covered by a case management protocol that included a home visit and by 0.92 microg/dL (0.04 micromol/L) among those covered by a protocol that included a lead source investigation. The decline remained significant after we adjusted for the child's age. CONCLUSION: These findings suggest that childhood lead prevention programs should consider focusing their efforts on home visits and lead source investigations.

Case Management↗

PubMed1992

[Family practice management in urethritis. II. Comparison of clinical management to the protocol].

OBJECTIVE: To describe general practitioners' approach to and management of urethritis in men, and to compare this with a general practice protocol for urethritis. DESIGN: Descriptive. SETTING: General practices in Amsterdam. PATIENTS AND METHODS: In 13 general practices in Amsterdam (23,510 patients, of whom 11,627 men) all episodes of urethritis in men (n = 55) were recorded during one year (complaints, medical management, diagnosis, medication, follow-up). OUTCOME MEASURES: Description of the diagnostic and therapeutic approach and the course of episodes; rough comparison with the urethritis protocol. RESULTS: In 25% the urine sediment was examined; other office tests were rarely performed. In 30 to 40% out of office microbiological tests were performed. In 50% of new diagnoses medication was underdosed, in some cases medication was wrong or not broad enough. In 25% explicit education was offered. In 22% new medication was given in the follow-up encounter. CONCLUSIONS: (Comparison with protocol.) Urine sediment examination as an effective test is performed insufficiently often. Other office tests are rarely performed, in accordance with the protocol. Out of office microbiological tests are performed too often, judged by the few changes of diagnosis and the character of new medication in the follow-up. First treatment is often underdosed and sometimes wrong. First treatment should preferably be broad, adequately dosed and independent of out of office microbiology. Too little education is given concerning the risks of ascending infections in female partners and of HIV infection. The referral rate is very low. It is important to pay attention to the outcome of this study in (postgraduate) education for general practitioners, as they treat the vast majority of urethritis patients.

Anti-Infective Agents, Urinary↗

PubMed1991

Prenatal management of twin gestation. Experience with a new protocol.

We carried out a prospective cohort study to evaluate the usefulness of a specific protocol of prenatal management of twin pregnancy to decrease the incidence of prematurity in the population. The protocol particularly stressed the importance of early recognition of uterine contractile activity and early work leave (from 28 weeks' gestation). The outcome of 39 consecutive twin pregnancies that used the protocol over a five-year period was compared with the outcome of 76 twin pregnancies followed by private practitioners and delivered at our department. The two groups were comparable with respect to maternal age, parity, gestational age at diagnosis, socioeconomic level and educational level. The incidence of preterm delivery was significantly lower in the study group than in the control group. Even more significant was the difference in the incidence of severe prematurity (less than 34 weeks' gestation) between the two groups. The use of a protocol like ours, which does not include prolonged hospitalization, home bed rest or tocolytic treatment, is recommended.

Adult↗

PubMed1991

Better quality studies through review of protocols.

The importance of a protocol is well recognized by scientists whose work is governed by good laboratory practices. Epidemiologists have used protocols for many years but have not always reaped the full benefits. Until relatively recently, there has been little consensus among epidemiologists about what constitutes a good protocol and, consequently, expectations of the pre-study review process may not be fulfilled. This paper examines some of the benefits to be derived from a good protocol and the importance of prestudy review. Our experience suggests that peer review cannot substitute for a competent principal investigator supported by a strong study management team. If such a study management team exists, the most important contribution of the external peer reviewer should be to ensure the impartiality of the study.

Clinical Protocols↗

PubMed1990

Postanesthesia care unit extubation protocol based on the Marker Model.

In an attempt to clearly define nursing practice in the PACU, nurses and anesthesiologists worked collaboratively to develop an extubation protocol. The protocol is for patients no longer requiring mechanical ventilation and who will be extubated in the PACU. The protocol is unique in that it is written in a format derived from the Marker Model. Using a hierarchical concept, the Marker Model provides a framework for dividing nursing standards into three categories: structure, process, and outcome. While the extubation protocol illustrates an example of a process standard, the article also focuses on briefly describing the major components of the Marker Model and how they interrelate.

Clinical Protocols↗

PubMed1990

Evaluation of a perinatal autopsy protocol: influence of the Prenatal Diagnosis Conference Team.

This study was designed to evaluate changes in the perinatal autopsy following the adoption of a new autopsy protocol. The University of Utah Medical Center has a Prenatal Diagnosis Conference Team composed of obstetricians, pediatricians, geneticists, and other health care professionals. These individuals are involved in the care of patients whose pregnancies are at risk for congenital malformations. An autopsy protocol was designed to increase the interaction of the pathologist with the Prenatal Diagnosis Conference Team in the evaluation of perinatal death. Two years, 1982 and 1987, before and after the protocol was implemented, were selected for retrospective review. The autopsies in 1987 made more specific diagnoses compared with those in 1982. Additional congenital anomalies were diagnosed, and increased numbers of patients were found to have well-described congenital disorders. The number of attempted postnatal autopsy chromosome studies increased and more chromosomal abnormalities were detected. The final autopsy diagnoses made in 1987 have provided more information to the physician for genetic or other patient counseling. After the protocol was adopted, increased numbers of cases were referred to the Medical Center for evaluation at autopsy. More of those who came to autopsy had been evaluated during life by members of the Prenatal Diagnosis Conference Team. Premortem sonograms had been done at an earlier gestational age and a greater number of anomalies were detected. Fewer of the fetuses had intrauterine death and more had pregnancy terminated by induction of labor. The gestational age at delivery declined.

Autopsy↗

PubMedDate not supplied

[A parametric description of the parenteral nutrition protocols of 19 American hospitals].

In the preparation of a centralized parenteral nutrition unit project in our hospital, following the creation of a multi-disciplinary commission entrusted with the study of this project, we proceeded to evaluate parenteral nutrition protocols of national and foreign hospitals, as a first approach to the subject. This study evaluates and extracts the data we consider most relevant in a sample of 19 American hospitals. With regard to the types of parenteral diet, we observed that most of them (63%) had "standard diets", mainly formulated with 25% glucose and 4.25% crystalline amino acids. None of the protocols studied contained alternatives to glucose as a calorie-contributor, nor were there special formulae for amino acids, although many of them included it in their therapies for use if considered necessary. In all protocols, the contribution of fats was reduced to concrete situations and administered in a different way to the rest of the food in 73% of cases. With regard to additives, despite the existence of standard formulations of electrolytes and vitamins and oligoelements, in 100% of the hospitals studied, there was the possibility of formulating each element separately. Administration was done in several doses per day in 42% of cases and in 100%, using perfusion pumps. The data obtained from this review was of great value in preparing our own parenteral nutrition protocols.

Canada↗

PubMed1988

Cancer treatment protocols. Who gets chosen?

We compared the age distribution of all adults in New Mexico with cancer incident from 1959 through 1982 with that of all adult New Mexican patients enrolled in cancer treatment protocols sponsored by the Southwest Oncology Group (New Mexico). For all cancer sites, elderly patients were substantially underrepresented in the Southwest Oncology Group protocols. While 31% of all adult patients with cancer were over age 70 years, only 7% of patients with cancer enrolled in Southwest Oncology Group protocols were in that age group. The underrepresentation of elderly individuals in cancer treatment protocols will make it difficult to determine optimal therapies for older patients with cancer.

Age Factors↗

PubMed1987

[Non-Hodgkinś lymphoma in childhood, preliminary results of the LSA2 L2 protocol modified by high-dose methotrexate].

From january 1982 to january 1986 we treated 23 pediatric patients who had non Hodgkin's lymphoma, with a new therapeutic protocol. This protocol is based on the LSA2 L2, modified during the induction phase with high-dose methotrexate and increasing of intrathecal therapy. Nineteen patients (83%) were in stages III and IV and the 47.4% were in stage IV. The distribution according to histology was: 10 Burkitt's undifferentiated lymphomas; 2 non-Burkitt's undifferentiated lymphomas; 5 lymphoblastic lymphomas convoluted-cells; 5 lymphoblastic lymphoma non-convoluted cells and 1 indeterminate lymphoma. The follow-up oscillated between 6 months and 4 years. The total survival rate is 82.6% with a 100% survival in stages I, II and III and 63.5% in stage IV. The survival according histology is 91.7% for undifferentiated lymphomas and 70% for lymphoblastic lymphomas; the actuarial survival rates in the two groups at 30 months are 87% and 55% respectively (p greater than 0.10). We concluded that adding high-dose methotrexate to the LSA2 L2 protocol improve the survival rate in undifferentiated lymphomas and in a less extent in lymphoblastic lymphomas, without significant toxicity. This new protocol is mainly indicated in undifferentiated and indeterminate non-Hodgkin's lymphomas.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1995

Effect of a standardized rewarming protocol and acetaminophen on core temperature after coronary artery bypass.

BACKGROUND: Cardiac surgical patients who require hypothermic cardiopulmonary bypass experience hypothermia, normothermia, and hyperthermia during the early postoperative period. Research-based rewarming protocols are needed to manage temperature variations. OBJECTIVE: To describe the effect of a standardized rewarming protocol and acetaminophen on the following outcome variables: core temperature, peak core temperature, rewarming time, and hyperthermia. METHODS: Patients (N = 60) were rewarmed using a standardized rewarming protocol. Electric heating blankets were used for subjects with core temperatures less than 36 degrees C on admission to the intensive care unit; other subjects were covered with cotton bath blankets. Subjects were also assigned to one of three acetaminophen groups (650 mg at 38.1 degrees C, 650 mg at 37 degrees C, 1300 mg at 37 degrees C). RESULTS: Using the protocol, subjects warmed to normothermia in 3.6 to 6 hours. The 16-hour core temperature thermal curves of heating blanket versus cotton bath blanket subjects differed significantly; thermal curves of the acetaminophen groups were similar. Peak core temperature was significantly lower in heating blanket subjects and unaffected by acetaminophen group. The onset of hyperthermia was not significantly affected by the method of rewarming (electric heating blanket versus cotton blankets) or acetaminophen group. Rewarming time was significantly longer for electric heating blanket subjects. CONCLUSIONS: Our results indicate that mildly hypothermic subjects rewarmed with electric heating blankets during the early postoperative period have lower peak core temperatures and longer rewarming times than those rewarmed with cotton bath blankets. Acetaminophen administration at normothermia does not significantly affect peak core temperature or the onset of hyperthermia.

Acetaminophen↗

PubMed1995

Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit.

Inappropriate benzodiazepine dosing in patients exhibiting signs of alcohol withdrawal cause staff and patient safety problems. Our primary goal was to develop an alcohol withdrawal protocol based on objective measures, and then to coordinate benzodiazepine dosing with those measures and improve care of the patient withdrawing from alcohol. A secondary goal was to give the primary care nurse the flexibility to administer benzodiazepine doses as needed to improve patient and staff safety. We developed and implemented a modified version of a published withdrawal symptomatology scale; a corresponding scale was developed for benzodiazepine dosing by observing the usual lorazepam doses needed to control withdrawal symptoms. Both scales and care guidelines for the patient withdrawing from alcohol were organized in the form of preprinted orders. Since implementation of the alcohol withdrawal protocol, complaints regarding patient and staff safety have decreased. Other patient care units are beginning to use the protocol. A hospital-wide task force is developing patient care plans based on the protocol for all patients withdrawing from alcohol.

Alcohol Withdrawal Delirium↗

PubMed1994

[Should laparoscopic lymphadenectomy modify the therapeutic protocols for cancer of the cervix?].

A precise evaluation of lymph node involvement in cases of cancer of the cervix can be obtained by performing laparoscopic lymphadenectomy. This technique has a sensitivity and a specificity of almost 100%, and is currently the best way to diagnose nodal involvement, apart from laparotomy. However, the role of laparoscopic lymphadenectomy in therapeutic protocols has not been precisely defined. The possibility of knowing beforehand the status of the lymph nodes has led to the proposal of new protocols where treatment modalities would be adapted to the findings of an initial laparoscopic lymphadenectomy. Three protocols have been proposed: some authors counterindicate colpohysterectomy in N+ patients and reserve surgery for N-patients: however, this attitude does not take into account current knowledge of tumour radiosensitivity. In case of an exclusive radiotherapy, radiotherapy could be adapted according to laparoscopic findings, but the benefit of surgical exercsis would be lost and patients would then be exposed to late pelvic relapse. Finally, laparoscopic lymphadectomy could be used in the treatment of early stage cancers, in association with a vaginal colpohysterectomy. Morbidity and survival rates of studies currently being conducted are still needed to evaluate this last protocol. Until these results are known, associating radiotherapy and colpohysterectomy remains the reference technique in cases of cancer of the cervix.

Clinical Protocols↗

PubMed1993

Protocol for out-patient management of dengue illness in young adults.

A prospective study on the practicality of an out-patient management protocol for dengue infection in adults was carried out during a 2-month period. Doctors were requested to follow the protocol and assessment was done on the patients' outcome, the admission rate, and the compliance to the protocol by doctors and patients. One hundred and sixty-two patients (mean age 27.3 years) were clinically diagnosed to have dengue illness. Among them, 82.7% had dengue fever (DF); 13.0% had dengue haemorrhagic fever (DHF) and 4.3% had dengue shock syndrome (DSS). Dengue aetiology was confirmed in 69.4% of the DF group and 85.7% of the DHF and DSS groups. There were no deaths among the 162 patients. The admission rate was 43.8%. A high compliance rate of 86.4% by the doctors and a low patient default rate of 16.4% showed that the protocol was practical.

Adolescent↗

PubMed1993

Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding.

BACKGROUND: Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding. OBJECTIVE: To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects. METHOD: Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute. RESULTS: Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction. CONCLUSIONS: Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.

Bradycardia↗

PubMed1993

[Thrombolytic therapy in acute myocardial infarct. New performance protocols. Their influence on mortality and the incidence of complications].

The new protocols of actuation in acute myocardial infarction thrombolysis have increased the number of patients treated, and have changed their characteristics. To assess the influence that this event has had in the complications incidence and mortality rate, we revise 704 infarcts treated with thrombolytic in a coronary unit, during 8 years. We separate two groups: 1) Patients treated since november 1983 to december 1988 following the established protocol at the beginning of this therapeutic (n = 328). 2) Patients treated since this date to july 1991, with a new protocol that include older than 70 years patients, moore than 6 hours of therapeutics delay and use of another thrombolytics, moreover streptokinase (n = 376). These changes have increased the number of thrombolysis in the second group (24.6 vs 49.1%; p < 0.001). Nevertheless being a higher group of risk we have found neither a significant mortality increase (6.40 vs 7.71%; p = NS), nor complications related to the thrombolysis: The incidence of major hemorrhages were 2.13 vs 1.06% (p = NS), cerebral hemorrhages 0.91 vs 1.6% (p = NS), hypotension related to the thrombolytics 15.55 vs 5.85% (p < 0.001). Neither has had significant difference in the incidence of reinfarcts (6.42 vs 5%; p = NS). In conclusion, the great number of thrombolysis realized nowadays, due to the actuation protocols changes, have increased significantly, neither the complications related with this therapeutic, nor the mortality rate, nor the reinfarcts number.

Aged↗

PubMed1995

Protocol care for hypertension supported by an expert system.

1. PURPOSE. Hypertension if one of the major prevalent diseases that influences the prognosis of chronic diseases. Primary care should attract much attention in the management of hypertension. The management of hypertension includes not only the use of antihypertensiove drugs, but also the modification of unhealthy lifestyles. Multi-dimensional approaches are required for the management of hypertensive patients. This system supports the standard protocol care for hypertensive patients and the database for clinical epidemiology. 2. DESIGN CONSIDERATIONS. This system has several functions that support the appropriate management of hypertensive patients. The first one is clinical database management. The second is the evaluation of the clinical conditions in hypertension. The third is the decision support system for the selection of treatments for hypertension. 3. SYSTEM DESCRIPTION. This system administers the clinical database, which includes symptoms and signs, laboratory data, and prescriptions. The database deals with the temporal course of the patient's status. The system that evaluates the patient's condition and the decision support system have some knowledge bases. The knowledge bases consist of the evaluation of the patient's condition, the appropriate selection of laboratory examinations, and suggestions for treatments, which involve a life-style modification and the proper prescription of medication. 4. STATUS REPORTS. The relational database was developed for handling the patient's records. These records were displayed on the terminal according to the temporal sequence. The graphical representations of the medical data were displayed in order to understand the patient's status. 5. LESSON LEARNED. This kind of protocol care system is expected to support the proper medical care of patients. Excess medications and laboratory examinations will be excluded under the protocol care, thus reducing unnecessary medical expense. The system will enhance the randomized clinical trials that verify the effects of the treatments. Violation of the protocol care is treated according to the several levels. 6. FUTURE PLANS. This system will be introduced to the occupational health care fields. The efficacy of improving the clinical quantity, and the effect of reducing the medical budget concerning hypertension will be verified.

Clinical Protocols↗

PubMed1996

Developing a local protocol for the management of lipid disorders in general practice.

Guidelines and protocols are increasingly becoming part of routine clinical practice. A standardised methodology has been proposed for the development of national guidelines based on principles which are known to effect validity. However, less is known about the most appropriate methodology for the development of local protocols. A case study is presented of the development of a local protocol for the management of lipid disorders in primary care in Grampian. It highlights the practicalities of such a process and identifies lessons for others who may wish to develop local protocols.

Clinical Protocols↗