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At least 487 records · Page 27Linked to original sources
PubMed2004

Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study.

OBJECTIVE: Recently, evidence-based clinical practice guidelines for the provision of nutrition support in the critical care setting have been developed. To validate these guidelines, we hypothesized that intensive care units whose practice, on average, was more consistent with the guidelines would have greater success in providing enteral nutrition. DESIGN: Prospective observational study. SETTING: Fifty-nine intensive care units across Canada. PATIENTS: Consecutive cohort of mechanically ventilated patients. INTERVENTIONS: In May 2003, participating intensive care units recorded nutrition support practices on a consecutive cohort of mechanically ventilated patients who stayed for a minimum of 72 hrs. Sites enrolled an average of 10.8 (range, 4-18) patients for a total of 638. Patients were observed for an average of 10.7 days. MEASUREMENTS AND MAIN RESULTS: We examined the association between five recommendations from the clinical practice guidelines most directly related to the provision of nutrition support (use of parenteral nutrition, feeding protocol, early enteral nutrition, small bowel feedings, and motility agents) and adequacy of enteral nutrition. We defined adequacy of enteral nutrition as the percent of prescribed calories that patients actually received. Across sites, the average adequacy of enteral nutrition over the observed stay in intensive care unit ranged from 1.8% to 76.6% (average 43.0%). Intensive care units with a greater than median utilization of parenteral nutrition (>17.5% patient days) had a much lower adequacy of enteral nutrition (32.9 vs. 52.7%, p < .0001). Intensive care units that used a feeding protocol tended to have a higher adequacy of enteral nutrition than those that did not (44.9 vs. 38.5%, p = .03). Intensive care units that initiated enteral nutrition on >50% of their patients within the first 48 hrs had a higher adequacy of enteral nutrition than those that did not (48.1 vs. 34.4%, p < .0001). Intensive care units that had a >50% utilization of motility agents and/or any small bowel feedings in patients with high gastric residuals tended to have a higher adequacy of enteral nutrition than those intensive care units that did not (45.6 vs. 39.2%, p = .04, and 48.4 vs. 41.8%, p = .16, respectively). CONCLUSIONS: Intensive care units that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via enteral nutrition. Adoption of the Canadian clinical practice guidelines should lead to improved nutrition support practice in intensive care units. This may translate into better outcomes for critically ill patients receiving nutrition support.

Adolescent↗
PubMed2002

An XML-based system for the flexible classification and retrieval of clinical practice guidelines.

Beneficial effects of clinical practice guidelines (CPGs) have not yet reached expectations due to limited routine adoption. Electronic distribution and reminder systems have the potential to overcome implementation barriers. Existing electronic CPG repositories like the National Guideline Clearinghouse (NGC) provide individual access but lack standardized computer-readable interfaces necessary for automated guideline retrieval. The aim of this paper was to facilitate automated context-based selection and presentation of CPGs. Using attributes from the NGC classification scheme, an XML-based metadata repository was successfully implemented, providing document storage, classification and retrieval functionality. Semi-automated extraction of attributes was implemented for the import of XML guideline documents using XPath. A hospital information system interface was exemplarily implemented for diagnosis-based guideline invocation. Limitations of the implemented system are discussed and possible future work is outlined. Integration of standardized computer-readable search interfaces into existing CPG repositories is proposed.

Information Systems↗
PubMed2004

Provider attitudes and beliefs about clinical practice guidelines.

The goals of clinical practice guidelines (CPG) are to improve the process and outcomes of health care, decrease practice variation, and optimize resource utilization. The objectives of this study were to (a) describe overall provider attitudes and beliefs about CPG, and (b) describe provider attitudes and acceptance of two specific spinal cord injury (SCI) CPG. A total of 152 health care providers responsible for implementation of the CPG at participating Veterans Health Administration (VHA) SCI sites responded to a survey (response rate of 35%). Overall, SCI care providers expressed positive attitudes towards CPG, including the two SCI guidelines included in this study. A comparison of responses revealed relatively few areas in which differences existed among SCI facilities and provider groups. Nurses represented the largest provider group participating in this survey and consistently expressed the most positive responses. In particular, nurses were more positive about guidelines, recognized the benefits of the guidelines, and were more willing to support the development of guidelines, compared to other providers in the study. The results of this study suggest that negative attitudes and beliefs about guidelines might be less of an obstacle to guideline implementation in VHA SCI Centers. Nurses are in a position to play a key role in their implementation.

Adult↗
PubMed1996

General practice training in Uganda. Part 2: Training program and clinical practice.

Enabling a developing country to become self-sufficient in health care is a major feat. This two-part article outlines how a general practice training project was established in Uganda to prepare postgraduate students to work in rural hospitals. The first part looked at the setting, personnel, and facilities. Part 2 outlines the curricula and clinical practice.

Canada↗
PubMed2000

[Remarks about good clinical practice].

In September 1998 Polish translation of the newest Good Clinical Practice version was issued by Polish Department of Health and Social Care. It is essential for all investigators who carry out the clinical researches involving human subjects to become acquainted with the Good Clinical Practice principles.

Clinical Protocols↗
PubMedDate not supplied

Developing recommendations to promote the uptake of research information in clinical practice.

This paper is aimed at highlighting some often overlooked aspects of the development of recommendations for clinical practice, and at addressing some of the key factors that can play a role as determinants of the acceptability of recommendations in clinical practice by the targeted health care providers. It is contended that, even in areas of clinical practice where clearcut recommendations could easily be drawn from the available evidence and apparently the issue at stake is just to transfer the appropriate message to the targeted audience, it is important to acknowledge--from the development stage of the recommendations--the complexity and the role of non-scientific key determinants (i.e. beliefs, values, vested interests) of clinical behaviour.

Clinical Nursing Research↗
PubMedDate not supplied

Evidence-based nursing in clinical practice: implications for nurse educators.

To improve patient outcomes currently and in the future, it is important that an evidence-based approach to nursing care be incorporated into clinical practice settings. Nurse educators and clinical nurse educators have a mandate to model and facilitate evidence-based nursing through learning activities. Unfortunately, issues present within clinical practice settings have made this approach difficult for registered nurses to fully incorporate into practice. This article outlines issues inhibiting evidence-based nursing, such as time factors, access to information and resources, nurses' research knowledge, skills, and learning opportunities, and the current nursing culture. Strategies for change that can be used by clinical nurse educators to enhance the use of evidence-based nursing in clinical practice areas are also described.

Clinical Competence↗
PubMed2003

Evidence-based practice in rural and remote clinical practice: where is the evidence?

OBJECTIVE: To critically review the evidence regarding barriers to implementing research findings in rural and remote settings, and the ways those barriers have been addressed. DESIGN: A systematic review that included searching several electronic databases, Internet sites and reference lists of relevant articles, assessment of methodological quality of the studies, and data extraction and analysis where possible. Eligibility for the review was not limited by study design. SETTINGS/PARTICIPANTS: Studies that reported on: (1) barriers to the implementation of evidence by health professionals in rural and remote areas, or (2) interventions for implementing evidence-based practice or an element of evidence-based practice in rural and remote areas. RESULTS: There were no experimental data available on the implementation of research findings in rural and remote clinical settings. The small amounts of empirical research undertaken (surveys) showed that some of the problems experienced by general practitioners were exacerbated by rural and remote location, particularly with relation to isolation, lack of time and locum cover, and poor information technology infrastructure. CONCLUSION: There is a paucity of empirical literature on implementing evidence-based practice in rural and remote settings. This is in contrast to the large amount of literature available on implementing evidence in other clinical settings. A clear finding from the literature was that getting evidence into practice needs to be context-specific and yet very little research has been conducted into the rural and remote context. Research is needed into how evidence can be implemented in contextually specific ways in rural and remote areas.

Data Interpretation, Statistical↗
PubMed1980

Percutaneous fine-needle aspiration biopsy. I. Its value to clinical practice.

From the experiences in dealing with 2591 cases of transthoracic and transabdominal fine-needle aspiration biopsies (1967-1978), we present our views on the value of this relatively new diagnostic method to clinical practice. Virtually any accessible localized lesion in any organ of the body can be investigated by fine-needle aspiration biopsy, which is considered most useful in patients with suspected malignant disease. Transthoracic and transabdominal fine-needle aspiration biopsy may provide information otherwise obtainable only by thoracotomy or laparotomy. It is an inexpensive and safe method with high accuracy for obtaining a pathologic diagnosis, and can impart some practical significance to clinical practice, especially in clinical management. The pitfalls in cytomorphologic interpretation, which often cause unsuccessful attempts, can be readily avoided with increased practical experience, as indicated by the increase in detection rate of lung cancer by fine-needle aspiration method from 82.8% in 1967-1968 to 93.4% in 1976 at the Toronto General Hospital. The accuracy of cytologic diagnosis plays a major role in spreading this still relatively unfamiliar but excellent diagnostic method. We believe that the method deserves widespread clinical application and when this happens, it will bring about great savings in health care resources.

Abdomen↗
PubMed1992

Implementing clinical practice guidelines: social influence strategies and practitioner behavior change.

Clinical practice guidelines offer potentially valuable tools for rationalizing health care delivery and improving patient outcomes. Currently, major efforts are under way to develop, test, and refine guidelines for a wide variety of medical conditions and procedures. Although methods for producing guidelines are fairly well understood and continue to improve, experience suggests that guidelines rarely translate directly into changes in practice. For various reasons, including physician resistance or incomplete understanding of the need for guidelines, they have proven difficult to implement. This article describes a broad range of strategies for implementing clinical practice guidelines based on the social influences that affect health practitioner behavior. The article also examines issues surrounding the selection and use of individual strategies or combinations of strategies in specific efforts to improve the quality of health care.

Attitude of Health Personnel↗
PubMed2005

Implications of pharmacogenomics for drug development and clinical practice.

Pharmacogenomics is likely to be among the first clinical applications of the Human Genome Project and is certain to have an enormous impact on the clinical practice of medicine. Herein, we discuss the potential implications of pharmacogenomics on the drug development process, including drug safety, productivity, market segmentation, market expansion, differentiation, and personalized health care. We also review 3 challenges facing the translation of pharmacogenomics into clinical practice: dependence on information technology, limited health care financing, and the scientific uncertainty surrounding validation of specific applications of the technology. To our knowledge, there is currently no formal agenda to promote and cultivate innovation, to develop progressive information technology, or to obtain the financing that would be required to advance the use of pharmacogenomic technologies in patient care. Although the potential of these technologies is driving change in the development of clinical sciences, it remains to be seen which health care systems level needs will be addressed.

Animals↗
PubMedDate not supplied

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia.

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

Adult↗
PubMed2006

SPECT/CT imaging using a spiral CT scanner for anatomical localization: Impact on diagnostic accuracy and reporter confidence in clinical practice.

PURPOSE: To evaluate the incremental benefit in routine clinical practice of computed tomography (CT) scans acquired for anatomical localization on an integrated SPECT/CT which incorporates a spiral CT scanner, in comparison with conventional planar and SPECT scanning. METHODS: The first 50 studies acquired on the integrated system were evaluated by two experienced nuclear medicine physicians who were aware of the patient's clinical history. These included bone scans, gallium scans, octreotide scans, sestamibi parathyroid scans and MIBG scans. For each patient study, abnormalities were assessed on planar and SPECT images for location and provisional diagnosis and a quantitative scale was used to assess reporter confidence. The fused SPECT/CT images were then reviewed and the location and provisional diagnosis noted and reporter confidence was assessed using the same quantitative scale. RESULTS: There were 129 abnormalities detected in 50 patient studies. For localization of abnormalities, the inclusion of the CT resulted in a minor change in 16% of cases and a significant change in 11% over planar/SPECT imaging alone. The confidence of localization was improved moderately in 19% and improved significantly in 6%. For diagnosis, SPECT/CT resulted in a minor change in 10% and a significant change in 9% over planar/SPECT imaging. The confidence of diagnosis was improved moderately in 10% and improved significantly in a further 10% of cases. For the final scan interpretation, there would have been no change in 44% patients, a minor change in 30% and a significant change in 26% with the use of SPECT/CT. CONCLUSION: Use of integrated SPECT/CT with a high spatial resolution, spiral CT used for anatomical localization improves accuracy and reporter confidence in clinical practice. As a result, final reports were different in 56% of the cases, including being significantly different in 26% patients compared to reporting with planar/SPECT alone.

Equipment Failure Analysis↗
PubMed2000

Clinical practice guidelines and the computer on your desk.

The majority of Australia's general practitioners are now believed to be using a computer to support clinical practice. This technology has the potential to deliver evidence-based clinical practice guidelines to the GP during consultations. If clinical practice guidelines are to be incorporated into electronic medical record systems, to assist clinical decision making at the point of care, guideline development will need to be significantly revised. Computerised clinical decision support at the time of consultation may become a major method for continuing medical education for Australian GPs.

Australia↗
PubMed1991

Measuring the ability of clinical pharmacists to effect drug therapy changes in a family practice clinic using prognostic indicators.

This study was designed to analyze physicians' acceptance of pharmacists' drug therapy recommendations in a Family Practice Clinic. It also measured the relationship between specific prognostic indicators and pharmacists' recommendations regarding drug therapy in individual patients. Once the recommendations were implemented, outcome data were collected to assess the impact on patient care. Thirty-nine patients were seen by a pharmacist during 49 clinic visits. A total of 36 recommendations were made to change therapy. Recommendations to change therapy occurred most frequently when one indicator, medication regimen changed four or more times during the past year, was present. Recommendations were accepted by physicians in 32 or 89% of cases. Patient outcome improved in 95% (18 of 19) of cases and remained unchanged in 5% (1 of 19) of cases for which outcome data were available.

Attitude of Health Personnel↗
PubMed1998

Run-in periods in randomized trials: implications for the application of results in clinical practice.

Prerandomization run-in periods are being used to select or exclude patients in an increasing number of clinical trials, but the implications of run-in periods for interpreting the results of clinical trials and applying these results in clinical practice have not been systematically examined. We analyzed illustrative examples of reports of clinical trials in which run-in periods were used to exclude noncompliant subjects, placebo responders, or subjects who could not tolerate or did not respond to active drug. The Physicians' Health Study exemplifies the use of a prerandomization run-in period to exclude subjects who are nonadherent, while recent trials of tacrine for Alzheimer disease and carvedilol for congestive heart failure typify the use of run-in periods to exclude patients who do not tolerate or do not respond to the study drug. The reported results of these studies are valid. However, because the reported results apply to subgroups of patients who cannot be defined readily based on demographic or clinical characteristics, the applicability of the results in clinical practice is diluted. Compared with results that would have been observed without the run-in period, the reported results overestimate the benefits and underestimate the risks of treatment, underestimate the number needed to treat, and yield a smaller P value. The Cardiac Arrhythmia Suppression Trial exemplifies the use of an active-drug run-in period that enhances clinical applicability by selecting a group of study subjects who closely resembled patients undergoing active clinical management for this problem. Run-in periods can dilute or enhance the clinical applicability of the results of a clinical trial, depending on the patient group to whom the results will be applied. Reports of clinical trials using run-in periods should indicate how this aspect of their design affects the application of the results to clinical practice.

Clinical Protocols↗