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The purpose of this article is to outline the underlying assumptions, principles and processes of a continuous quality improvement approach which underpins the accreditation of general practice offered by Australian General Practice Accreditation Limited.
This guidance document on prudent use of antibiotics and other antimicrobial drugs has been produced for NHSScotland by the Scottish Medicines Consortium (SMC). It fulfils one of the requirements set out in the Antimicrobial Resistance Strategy and Scottish Action Plan (Scottish Executive Health Department 2002) and forms part of the Healthcare Associated Infection (HAI) Action Plan work programme overseen by the Ministerial HAI Task Force. The objective was the development of a set of Good Practice Recommendations for Antimicrobial Prescribing in Hospitals to be implemented at the national or local level. The publication of the recommendations of this document in the Journal of Antimicrobial Chemotherapy (JAC) aims to highlight the value of such a national framework to a broader national and international community, particularly aimed at those decision-makers involved in antimicrobial stewardship. While some of its content may only be applicable to a devolved Scottish Health Care system we feel that many of the principles and good practice points are of generic concern and would be of relevance and value to all acute hospitals. On behalf of the all the authors involved in producing this document it is our hope that this article will stimulate debate and action within our acute hospitals.
These clinical guidelines were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the use of light therapy for treatment of various sleep disorders. This paper is based on a series of articles in the Journal of Biological Rhythms and also includes evidence tables from an updated Medline review covering the period January 1994 to December 1997. Evidence is presented by grade and level. Recommendations are identified as standards, guidelines, or options. Recommendations are provided for delayed sleep phase syndrome (DSPS), advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome, jet lag, shift work, dementia, and sleep complaints in the healthy elderly. Light therapy appears generally safe if used within recommended intensity and time limits. Light therapy can be useful in treatment of DSPS and ASPS. Benefits of light therapy are less clear and treatment is an option in jet lag, shift work, and non-24-hour sleep-wake syndrome in some blind patients.
Organizations often do not have processes in place to support nurses through a systematic approach for developing and evaluating nursing interventions, protocols, critical pathways, and policies that are derived from scientific evidence. The development of a framework to guide inquiry will have a positive impact on patients. This process may foster a higher level of professional engagement by nurses that may, in the long-term, help improve nurse retention and recruitment. The authors discuss a nursing evidence-based practice model and guidelines that were developed by a team of hospital and academic nurse leaders and is practical and easy to use. This model has been successfully implemented across the department of nursing as a strategic initiative. Results of the implementation have shown that staff nurses can effectively use this model with the help of knowledgeable mentors.
The elevation of Family Medicine to the status of a recognized specialty is designed, at least in part, to enhance the attractiveness of family practice as a career alternative for physicians. This paper examines the attitudinal orientations of group of medical students and physicians toward family practice in an attempt to highlight some of the issues that might be anticipated as this new specialty develops. Based on the results, it is concluded that fundamental change in the nature of the medical education experience will be needed if greater numbers of physicians are to be involved in primary care.
This paper describes a teaching programme, for use in general practice vocational training, which provides a theoretical and practical framework for exploring key aspects of the consultation with trainees. A particular emphasis is on the educational or 'cognitive' outcomes of the consultation and skills for improving them. The five stages of the programme are described and an example of experience of each stage is given. The paper concludes with an evaluation of the programme by the trainers, trainees and social scientist involved.
This article describes a framework for evaluating and adapting existing practice guidelines for local use by health care organizations and groups. The framework presents the major issues related to guideline adaptation and breaks them down into manageable steps. Many steps of the framework are illustrated using the process used by the Registered Nurses Association of Ontario to develop best practice guidelines for breastfeeding.
Clinical practice guidelines (CPGs) have been used to reduce unnecessary and undesirable variations in clinical practice. Many facilities succeed in developing and using these tools, while others conclude that they are not worth the effort. This article describes the results of a systemwide analysis of the processes a healthcare system used to plan, develop, implement, and measure CPGs after several years of experience. Extensive interviews were conducted at facilities in which the CPG program was active to determine what factors had contributed to its success or failure. The result is a series of recommendations that will facilitate CPG implementation in virtually any clinical setting.
During a four-year study period 43 985 patients were seen in the treatment room and 61 806 coded procedures carried out. Thirty per cent of these procedures were not part of usual nursing curricula and required initial supervision and assessment or training (or both). Nearly 15% of the patients seen were making a first visit and did not require referral to a doctor. A further 17% were also making a first visit but were referred to a doctor. The treatment room made an important contribution to the work of the practice, but this would not have been possible if the staff concerned had been attached nurses requiring area health authority authorisation for procedures carried out as opposed to practice nurses for whom procedures were authorised on a personal basis.
OBJECTIVE: To assess the effectiveness of 12 weeks' treatment with a 24 hour transdermal nicotine patch in helping heavy smokers to stop smoking; also to assess the value of a specially written support booklet about smoking cessation and patch use compared with a simple advice pamphlet. DESIGN: Double blind placebo controlled randomised trial with a 2 x 2 factorial design. SETTING: 19 general practices in Oxfordshire. SUBJECTS: 1686 heavy smokers aged 25-64 (mean cigarette consumption 24/day; mean duration of smoking 25 years). MAIN OUTCOME MEASURE: Sustained cessation for the last four weeks of the 12 week treatment period, confirmed by saliva cotinine estimation (226/262 cases; 86.3%) or expired carbon monoxide concentration (36/262; 13.7%). Patients lost to follow up (155/1686; 9%) were assumed to have continued to smoke. RESULTS: Cessation was confirmed in 163 patients (19.4%) using the nicotine patch and 99 patients (11.7%) using the placebo patch (difference 7.6% (95% confidence interval 4.2% to 11.1%); p < 0.0001). There was no significant advantage in using the more detailed written support material. The most important adverse effect of the patch was local skin irritation, which occurred in 15.8% (133/842) and 5.1% (43/844) of patients using the nicotine and placebo patches respectively, was graded as severe in 4.8% (40) and 1.1% (nine), and was stated as a reason for withdrawal from the trial in 9.5% (80) and 2.8% (24). CONCLUSION: Nicotine patches are effective in a general practice setting with nursing support, but the extent to which this effect is sustained cannot be assessed until the results of longer term follow up are known.
Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.
BACKGROUND: The General Practice Research Database (GPRD) covers over 6% of the population of England and Wales and holds data on diagnoses and prescribing from 1987 onwards. Most previous studies using the GPRD have concentrated on drug use and safety. A study was undertaken to assess the validity of using the GPRD for epidemiological research into respiratory diseases. METHODS: Age-specific and sex-specific rates derived from the GPRD for 11 respiratory conditions were compared with patient consultation rates from the 4th Morbidity Survey in General Practice (MSGP4). Within the GPRD comparisons were made between patient diagnosis rates, patient prescription rates, and patient "prescription plus relevant diagnosis" rates for selected treatments. RESULTS: There was good agreement between consultation rates in the MSGP4 and diagnosis or "prescription plus diagnosis" from the GPRD in terms of pattern and magnitude, except for "acute bronchitis or bronchiolitis" where the best comparison was the combination category of "chest infection" and/or "acute bronchitis or bronchiolitis". Within the GPRD, patient prescription rates for inhalers, tuberculosis or hayfever therapy showed little similarity with diagnosis only rates but a similarity was seen with the combination of "prescription plus diagnosis" which may be a better reflection of morbidity than diagnosis alone. CONCLUSIONS: The GPRD appears to be valid for primary care epidemiological studies by comparison with MSGP4 and offers advantages in terms of large size, a longer time period covered, and ability to link prescriptions with diagnoses. However, careful interpretation is needed because not all consultations are recorded and the coding system used contains terms which do not directly map to ICD codes.
The objectives of this open-labeled study were to assess the clinical uroselectivity of alfuzosin in a long-term follow-up study in general practice. A total of 3,228 patients with clinical benign prostatic hyperplasia (BPH) from 812 centers were included in a prospective 3-year open-labeled study and treated with alfuzosin (immediate-release formulation) at the recommended dosage. Symptom score (Boyarsky, modified) and a 20-item BPH-specific health related quality of life (HRQL) score (Urolife BPH QoL 20), which included three questions on sexuality, were self-administered at baseline, 3, 6, 12, 18, 24, 30 and 36 months. Symptom score was significantly reduced by 54% at 3 months and this reduction was maintained up to 36 months; the HRQL score was significantly improved by 45.4% at 12 months and this improvement was also maintained up to 36 months. Alfuzosin was well tolerated: the quantitative and qualitative distribution of adverse events (AEs) was similar to that previously observed in placebo-controlled studies. 4.2% of the patients dropped out due to AEs. This study confirms the long-term safety profile of alfuzosin in general practice and highlights the need to measure HRQL in the context of clinical uroselectivity.
The academic practice of otolaryngology does not end after residency, nor does it depend upon employment in an academic institution or affiliate. Academic practice is a state of mind and a mode of living. It is a commitment to intellectual vitality, and to recognizing, but never accepting, the limits of our knowledge. It is a call to keep asking questions and to pursue answers methodically, and it is a commitment for each of us to leave the field of otolaryngology better than we found it.
This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed. All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P=0.15) with no inter-hospital differences (P=0.08-0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11-19.49, P< 0.001; one regional: OR 6.29, CI 95% 3.24-12.20, P<0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09-6.62, P<0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29-3.72, P=0.004). Bronchoscopy did not predict outcome (P=0.11) or appropriate antibiotic selection (P=0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11-13%, P=0.12) and hospitals (0-16%, P=0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16-0.90, P=0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23-0.72, P<0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02-0.13, P<0.001), suspected aspiration (OR 0.20, CI 95% 0.04-0.92, P=0.04), in one regional (OR 0.26, CI95% 0.07-0.97, P=0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03-0. 73, P=0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01-1.03, P=0.01). There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.
OBJECTIVES: To provide practical recommendations for monitoring patients both before and during treatment with atypical antipsychotics, to assist clinicians in implementing preventative measures against diabetes, and to establish baselines according to which clinicians should initiate diabetes treatment. METHOD: A working group of Canadian specialists in psychiatry and endocrinology reviewed peer-reviewed clinical studies published in this area and other relevant papers and abstracts. RESULTS: The reviewed studies further confirm that atypical antipsychotic medications are the most effective components in the medical management of many psychotic conditions; they also further emphasize the need to more stringently monitor and recognize diabetes risk factors inherent in these patients. Recommendations are based on a review of the available data, on expert opinion and consensus, and on current Canadian guidelines for the treatment of schizophrenia and management of diabetes. CONCLUSIONS: Patients with psychiatric disorders, most particularly schizophrenia and mood disorders, have an increased risk for type 2 diabetes and should be screened frequently, especially when other risk factors are present. The resulting recommendations offer practical steps for effectively screening patients prior to and during treatment with atypical antipsychotics. They include (1) how to conduct an initial baseline assessment, (2) when and how to monitor blood glucose and lipid levels, and (3) how to educate patients regarding such lifestyle issues as nutrition, exercise, and diet.
The Oncology Nursing Society (ONS) has worked diligently to improve the care of patients with cancer and their families. A recent project that demonstrates this commitment toquality care is the development of nursing-sensitive patient outcomes resources. ONS has teamed researchers, advanced practice nurses, and staff nurses to develop Putting Evidence Into Practice resources that provide guidance for nursing interventions based on the evidence. The ability to provide evidence for nursing interventions is critical to all aspects of patient care, including patient teaching, development of patient care policies and procedures, and provision of direct patient care.
BACKGROUND: Medical record audits have been used to provide physicians with feedback about their compliance with preventive health and disease management recommendations. PURPOSE: To determine if report cards summarizing medicine residents' preventive health and disease management practices can be used as a feedback tool to improve practice performance. METHODS: Randomized, blinded, controlled study of 44 internal medicine residents using an individualized 78-item report card based on outpatient record audits. RESULTS: Four hundred ninety-seven charts were retrospectively audited at baseline and 284 charts in follow-up. There were no significant differences in baseline performance between the residents in the intervention and control group. There were no differences in performance scores between residents receiving report cards and those who had not in immunizations, counseling, total preventive health, diabetes, hypertension, and total disease management. CONCLUSIONS: Intensive data-based feedback using report cards may not be a successful way to improve ambulatory performance of medical house officers.