AMDA Guidelines Clarify Treatment Goals

Implementing Pressure Ulcer Prevention and Treatment Programs: Using AMDA Clinical Practice Guidelines

Continence Care Options for the Long-Term Care Resident: A Supplement to the Journal of the American Medical Directors Association

A Clinical Practice Guideline Approach to Treating Depression in Long-term Care

BackgroundCommunication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists’ implementation of stroke CPGs. This study aimed to describe speech pathologists’ experiences and current use of guidelines, and to identify what factors influence speech pathologists’ implementation of stroke CPGs.MethodsSpeech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data.Results320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline “somewhat useful” or “very useful”. Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided.ConclusionsThere are many different factors that can influence speech pathologists’ implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

Clinical practice guidelines: who reads them? who needs them?

In 2020, our group published physical therapy clinical practice guidelines (CPG) for people with Huntington's disease (HD). The guideline recommendations were categorized according to six primary movement impairment classifications. To facilitate implementation of this CPG, we have developed guideline-based algorithms for physical therapy assessments and interventions and recommendations for therapists to overcome barriers to CPG implementation for people with HD. We conducted a literature review of papers that evaluated physical therapy interventions in individuals with HD (n = 26) to identify assessments for each of the primary movement impairment classifications, and then searched for papers (n = 28) that reported their clinometric/psychometric properties in HD. Assessments were evaluated using modified Movement Disorder Society Committee on Rating Scales criteria and other relevant criteria. We identified a "core set" of physical therapy assessments for persons with HD, including the Six Minute Walk Test, Timed Up and Go Test, Berg Balance Scale, and the Medical Outcomes Study Short Form 36 (SF-36). We then developed guideline-based decision trees to assist in decision making and implementation of the CPG into practice for persons with HD across the continuum of care. Finally, we developed strategies for overcoming barriers to implementation, such as seeking specialized training in HD, engaging caretakers or family members to help the person with HD to exercise, and establishing clinical pathways that support early physical therapy referrals. Knowledge translation documents such as this are essential to promoting implementation of the physical therapy CPGs into clinical practice.

The Policies of the American Medical Directors Association

Cancer care is evolving from a solo practitioner care delivery system based on tradition and anecdotal experience to a multidisciplinary, collaborative, science-driven paradigm. Evidence-based practice facilitates optimal care quality for patients with cancer and is effected for medical and nursing practitioners through clinical practice guideline implementation. Clinician education based on principles of adult learning is one method of implementing clinical practice guidelines in clinical practice. However, research demonstrates that conventional static methods of education do little to change behavior; instead, effective education incorporates interactive formats, provides feedback, and includes reminder and reinforcement strategies. The EDUCATE (Educating Clinicians to Achieve Treatment Guideline Effectiveness) Study offers one model for clinical practice guideline implementation using educational methods. A faculty of nurse educators, together with practice champions, carried out an intensive educational intervention comprised of multiple teaching/learning activities during a 12-month period in community oncology practices throughout the United States. In addition to an overview of clinical practice guidelines and educational methods that can be used for implementation of clinical practice guidelines, the obstacles faced and lessons learned through the EDUCATE Study are presented, along with recommendations for implementation in the practice setting.

To measure the effect of implementing quality improvement (QI) methodology on the rate of chest radiograph (CXR) ordering for pediatric patients with acute asthma exacerbations.A total of 6680 pediatric patients age ≥2 years seen in the emergency department (ED) of a tertiary care children’s hospital for acute asthma were included in the study.Children ≥2 years old were retrospectively identified by chart review from May 2013 to April 2017. Included subjects had a primary International Classification of Diseases, Ninth Revision or 10th Revision billing code for asthma. An asthma clinical practice guideline (CPG) for CXR ordering in the ED was implemented in May 2014. Thus, the data from May 2013 to April 2014 were included as a 1-year baseline before intervention. Additional QI methods included removal of CXR as a default component of the electronic medical record asthma order set (July 2015), public reminder placement (January 2016), and targeted resident education (February 2016). The primary measure was CXRs ordered as a percentage of total acute asthma encounters, with a preintervention goal of <20%.A total of 1539 CXRs were ordered during 6680 patient encounters. Hospital-wide implementation of an asthma CPG was associated with a decrease in CXR use in acute asthma visits, from 29.3% to 23.0%. Implementation of targeted QI measures was associated with a further reduction in CXR use to 16.0%, which was sustained for 14 months (from February 2016 to April 2017). CXR use decreased from 21.3% to 12.5% in the subset of patients discharged from the hospital from the ED and from 53.5% to 31.1% among patients ultimately admitted to the hospital.Investigators in this study describe sustained reduction in CXR ordering in pediatric patients with acute asthma exacerbations after implementation of a CPG, later followed by QI interventions targeted at the electronic medical record system and at provider education.Old habits die hard. Previous studies have established that routine use of CXR in the evaluation of children with acute asthma exacerbations, the most frequent cause of childhood hospitalization in the United States, is of low diagnostic yield and is associated with significant risk, including unnecessary antibiotic administration. Despite evidence demonstrating low utility of CXR in this setting, implementation of “best” practice into clinical routine is challenging and can take years before change occurs. This study demonstrates how QI methodology can help break old habits, improve clinical care through patient-centered outcome measures, and most importantly, assist clinicians working in busy medical settings. It is impossible for any of us to stay current with the rapidly evolving world of medical knowledge. That is why dedicated use of QI methodology and commitment to changing culture can be so valuable.

IntroductionBronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan.MethodsThe study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared.ResultsEighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24).ConclusionWe observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians’ behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

Late-onset sepsis (LOS) is a common cause of neonatal morbidity and mortality. Professional organizations recommend avoiding empiric vancomycin use in neonates without risk factors for methicillin-resistant Staphylococcus aureus infection. We aimed to reduce the mean vancomycin antibiotic utilization rate (AUR) by 30% for 12 months in our neonatal intensive care unit (NICU). We included neonates admitted to our level-3 NICU from March 15, 2023, to February 29, 2024, with suspected LOS in the intervention period. A multidisciplinary team used the Model for Improvement. Interventions tested using plan-do-study-act cycles included provider education, clinical practice guideline (CPG) implementation, and prospective audit with feedback (PAF). The outcome measure was the mean vancomycin AUR measured in days of therapy per 1,000 patients days, plotted monthly and analyzed for special cause variation. The process measure was CPG adherence. We tracked balancing measures related to morbidity and mortality. During the intervention period, 50 neonates underwent LOS evaluations. The mean vancomycin AUR decreased by 37.1%, from 27 to 17 days of therapy per 1,000 patient days, and was sustained postintervention. CPG adherence was 96%. Three neonates required changing from oxacillin to vancomycin for coagulase-negative staphylococci bacteremia (n = 2) and urinary tract infection (n = 1). There were no drug-related morbidity or sepsis-related mortality events. This quality improvement project allowed a safe, rapid and sustained reduction of NICU-wide vancomycin use. Provider education, CPG implementation, and PAF were critical to optimizing empiric antibiotic management.

BackgroundThere is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health.MethodsA systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised.ResultsFew (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes.ConclusionEvidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.

IntroductionMost studies have reported barriers to guideline usage mainly from doctors’ perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals.MethodsThis study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data.ResultsTwo main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use.ConclusionsBarriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.

You've Got to Have the Right Stuff

Teaching health sciences students how to evaluate and implement clinical practice guidelines (CPGs) is challenging. Physical therapist education offers experiential learning opportunities to teach students how to evaluate and implement CPGs. Knowledge translation (KT) guides the process of moving research evidence into practice. Experiential learning using KT principles can teach students to assess barriers to evidence use and overcome implementation challenges. The purpose of this retrospective phenomenological qualitative study was to explore the beliefs, perceptions, and experiences of former physical therapist students' who completed a neurologic elective course implementing 2 CPGs. Furthermore, how the course impacted their clinical experiences is also described. Nine third-year physical therapist students. Students who participated in an elective experiential learning course developed using KT principles were recruited. Focus groups were held to determine the students' perceptions and experiences with implementing CPGs in the classroom and during their clinical experiences. Content analysis was used to identify codes and categories, and they were aligned with the Consolidated Framework of Implementation Research. Trustworthiness was established through member checking, peer debriefing, and an external audit. Students reported individual and contextual facilitators during the elective that supported CPG use. Students identified improved knowledge, confidence, and skill to perform the CPGs that facilitated their transfer of knowledge from the classroom to the clinic. During their clinical experiences, students discussed contextual factors, such as culture, environment, and patient population, which served as both facilitators and barriers to CPG use. Experiential learning enhanced knowledge, confidence, and skill with using CPGs and facilitated students' integration of evidence-based practice into their clinical experiences. Where possible, physical therapy curricula should incorporate experiential learning with KT principles to help students identify barriers to CPG use and develop strategies to enhance future evidence-based practice implementation.