Reflective practice and guided discovery: clinical supervision.

PubMed

Todd, G; Freshwater, D

This article explores the parallels between reflective practice as a model for clinical supervision, and guided discovery as a skill in cognitive psychotherapy. A description outlining the historical development of clinical supervision in relationship to positional papers and policies is followed by an exposé of the difficulties in developing a clear, consistent model of clinical supervision with a coherent focus; reflective practice is proposed as a model of choice for clinical supervision in nursing. The article examines the parallels and processes of a model of reflection in an individual clinical supervision session, and the use of guided discovery through Socratic dialogue with a depressed patient in cognitive psychotherapy. Extracts from both sessions are used to illuminate the subsequent discussion.

Knowledge management strategies: Enhancing knowledge transfer to clinicians and patients.

PubMed

Roemer, Lorrie K; Rocha, Roberto A; Del Fiol, Guilherme; Bradshaw, Richard L; Hanna, Timothy P; Hulse, Nathan C

2006-01-01

At Intermountain Healthcare (Intermountain), executive clinical content experts are responsible for disseminating consistent evidence-based clinical content throughout the enterprise at the point-of-care. With a paper-based system it was difficult to ensure that current information was received and was being used in practice. With electronic information systems multiple applications were supplying similar, but different, vendor-licensed and locally-developed content. These issues influenced the consistency of clinical practice within the enterprise, jeopardized patient and clinician safety, and exposed the enterprise and its employees to potential financial penalties. In response to these issues Intermountain is developing a knowledge management infrastructure providing tools and services to support clinical content development, deployment, maintenance, and communication. The Intermountain knowledge management philosophy includes strategies guiding clinicians and consumers of health information to relevant best practice information with the intention of changing behaviors. This paper presents three case studies describing different information management problems identified within Intermountain, methods used to solve the problems, implementation challenges, and the current status of each project.

Transition From Clinical to Educator Roles in Nursing: An Integrative Review.

PubMed

Fritz, Elizabeth

This review identified barriers to and facilitators of nurses' transition from clinical positions into nursing professional development and other nurse educator roles. The author conducted literature searches using multiple databases. Twenty-one articles met search criteria, representing a variety of practice settings. The findings, both barriers and facilitators, were remarkably consistent across practice settings. Four practice recommendations were drawn from the literature to promote nurses' successful transition to nursing professional development roles.

A Mediation Model of Interparental Collaboration, Parenting Practices, and Child Externalizing Behavior in a Clinical Sample

ERIC Educational Resources Information Center

Kjobli, John; Hagen, Kristine Amlund

2009-01-01

The present study examined maternal and paternal parenting practices as mediators of the link between interparental collaboration and children's externalizing behavior. Parent gender was tested as a moderator of the associations. A clinical sample consisting of 136 children with externalizing problems and their families participated in the study.…

Clinical trial design in the neurocritical care unit.

PubMed

Hall, C E; Mirski, M; Palesch, Y Y; Diringer, M N; Qureshi, A I; Robertson, C S; Geocadin, R; Wijman, C A C; Le Roux, P D; Suarez, Jose I

2012-02-01

Clinical trials provide a robust mechanism to advance science and change clinical practice across the widest possible spectrum. Fundamental in the Neurocritical Care Society's mission is to promote Quality Patient Care by identifying and implementing best medical practices for acute neurological disorders that are consistent with the current scientific knowledge. The next logical step will be to foster rapid growth of our scientific body of evidence, to establish and disseminate these best practices. In this manuscript, five invited experts were impaneled to address questions, identified by the conference organizing committee as fundamental issues for the design of clinical trials in the neurological intensive care unit setting.

Medical Physics Practice Guidelines - the AAPM's minimum practice recommendations for medical physicists.

PubMed

Mills, Michael D; Chan, Maria F; Prisciandaro, Joann I; Shepard, Jeff; Halvorsen, Per H

2013-11-04

The AAPM has long advocated a consistent level of medical physics practice, and has published many recommendations and position statements toward that goal, such as Science Council Task Group reports related to calibration and quality assurance, Education Council and Professional Council Task Group reports related to education, training, and peer review, and Board-approved Position Statements related to the Scope of Practice, physicist qualifications, and other aspects of medical physics practice. Despite these concerted and enduring efforts, the profession does not have clear and concise statements of the acceptable practice guidelines for routine clinical medical physics. As accreditation of clinical practices becomes more common, Medical Physics Practice Guidelines (MPPGs) will be crucial to ensuring a consistent benchmark for accreditation programs. To this end, the AAPM has recently endorsed the development of MPPGs, which may be generated in collaboration with other professional societies. The MPPGs are intended to be freely available to the general public. Accrediting organizations, regulatory agencies, and legislators will be encouraged to reference these MPPGs when defining their respective requirements. MPPGs are intended to provide the medical community with a clear description of the minimum level of medical physics support that the AAPM would consider prudent in clinical practice settings. Support includes, but is not limited to, staffing, equipment, machine access, and training. These MPPGs are not designed to replace extensive Task Group reports or review articles, but rather to describe the recommended minimum level of medical physics support for specific clinical services. This article has described the purpose, scope, and process for the development of MPPGs.

The Instrument for Measuring the Implementation Situation of Traditional Chinese Medicine Guideline: Evaluation and Application

PubMed Central

Wang, Yangyang; Chen, Yaolong; Wang, Xiaoyun; Deng, Jingwen

2017-01-01

Clinical practice guidelines play an important role in reducing the variations in clinical practices and improving the quality of care. To assess the real effect, measuring its implementation situation is needed. The implementation situation can be reflected by testing the consistency between the actual clinical practice and the guideline. We constructed an instrument to measure the implementation situation of Traditional Chinese Medicine (TCM) guideline through consistency testing. The main objectives of our study were to validate the instrument and evaluate the implementation situation of menopause syndrome guideline of TCM, using the data from the consistency test of comparing the medical records with the guideline. A total of 621 cases were included for data analysis. Cronbach's Alpha coefficient is 0.73. The model fit of 7 items in four dimensions was good (SRMR = 0.04; GFI = 0.97; NFI = 0.97; TLI = 0.96; CFI = 0.98; AGFI = 0.90). This instrument is of good reliability and validity. It can help the guideline developers to measure the implementation situation, find the reasons affecting the implementation, and revise the guideline. The method of using consistency test to measure the implementation situation may provide a sample for evaluating the guideline implementation in other fields. PMID:29234379

Semantic Clinical Guideline Documents

PubMed Central

Eriksson, Henrik; Tu, Samson W.; Musen, Mark

2005-01-01

Decision-support systems based on clinical practice guidelines can support physicians and other health-care personnel in the process of following best practice consistently. A knowledge-based approach to represent guidelines makes it possible to encode computer-interpretable guidelines in a formal manner, perform consistency checks, and use the guidelines directly in decision-support systems. Decision-support authors and guideline users require guidelines in human-readable formats in addition to computer-interpretable ones (e.g., for guideline review and quality assurance). We propose a new document-oriented information architecture that combines knowledge-representation models with electronic and paper documents. The approach integrates decision-support modes with standard document formats to create a combined clinical-guideline model that supports on-line viewing, printing, and decision support. PMID:16779037

Reliability and Validity of the Evidence-Based Practice Confidence (EPIC) Scale

ERIC Educational Resources Information Center

Salbach, Nancy M.; Jaglal, Susan B.; Williams, Jack I.

2013-01-01

Introduction: The reliability, minimal detectable change (MDC), and construct validity of the evidence-based practice confidence (EPIC) scale were evaluated among physical therapists (PTs) in clinical practice. Methods: A longitudinal mail survey was conducted. Internal consistency and test-retest reliability were estimated using Cronbach's alpha…

[Development and Effects of Assertiveness Training applying Dongsasub Training for Nursing Students in Clinical Practice].

PubMed

Kim, Myoungsuk

2016-08-01

This study was conducted to develop assertiveness training applying Dongsasub training for junior nursing students, and to verify effectiveness of the training on assertiveness behavior, self-esteem, clinical practice stress, and clinical competence. The study design was a non-equivalent control group non-synchronized design. Participants were 63 nursing students in clinical training (31 students in the experimental group and 32 students in the control group). The assertiveness training applying Dongsasub training consisted of four sessions. Outcome variables included assertiveness behavior, self-esteem, clinical practice stress, and clinical competence. Data were analyzed using Chi-square, Fisher's exact test and independent samples t-test with SPSS/WIN 21.0. Scores of assertiveness behavior (t=-2.49, p=.015), self-esteem (t=-4.80, p<.001) and clinical competence (t=-2.33, p=.023) were significantly higher and clinical practice stress (t=4.22, p<.001) was significantly lower in the experimental group compared to the control group. Results indicate that the assertiveness training applying Dongsasub training can be used as a nursing intervention to lower clinical practice stress and improve the clinical competence of nursing students.

Safe clinical practice for patients hospitalised in a suicidal crisis: a study protocol for a qualitative case study

PubMed Central

Berg, Siv Hilde; Rørtveit, Kristine; Walby, Fredrik A; Aase, Karina

2017-01-01

Introduction Suicide prevention in psychiatric care is arguably complex and incompletely understood as a patient safety issue. A resilient healthcare approach provides perspectives through which to understand this complexity by understanding everyday clinical practice. By including suicidal patients and healthcare professionals as sources of knowledge, a deeper understanding of what constitutes safe clinical practice can be achieved. Methods This planned study aims to adopt the perspective of resilient healthcare to provide a deeper understanding of safe clinical practice for suicidal patients in psychiatric inpatient care. It will describe the experienced components and conditions of safe clinical practice and the experienced practice of patient safety. The study will apply a descriptive case study approach consisting of qualitative semistructured interviews and focus groups. The data sources are hospitalised patients in a suicidal crisis and healthcare professionals in clinical practice. Ethics and dissemination This study was approved by the Regional Ethics Committee (2016/34). The results will be disseminated through scientific articles, a PhD dissertation, and national and international conferences. These findings can generate knowledge to be integrated into the practice of safety for suicidal inpatients in Norway and to improve the feasibility of patient safety measures. Theoretical generalisations can be drawn regarding safe clinical practice by taking into account the experiences of patients and healthcare professionals. Thus, this study can inform the conceptual development of safe clinical practice for suicidal patients. PMID:28132001

A qualitative evaluation of scalpel skill teaching of podiatry students.

PubMed

Causby, Ryan S; McDonnell, Michelle N; Reed, Lloyd; Fryer, Caroline E; Hillier, Susan L

2017-01-01

Degrees in health disciplines need a balance of theoretical knowledge and sufficient clinical practice to meet registration requirements, in particular those requiring specialist skills such as the use of scalpels and other small instruments, such as podiatry. However, despite this requirement there is a scarcity of literature and research to inform teaching of these particular manual clinical skills. Therefore, the aims of this study were to determine the current approaches being used to teach manual skills, in particular scalpel skills, in university podiatry programs in Australia and New Zealand, and to explore what issues, challenges and innovations exist. A qualitative study, consisting of semi-structured interviews with staff at eight university podiatry programs in Australia and New Zealand was undertaken to determine how these skills are taught and evaluated, and how poor performers are managed. A conventional content analysis technique was used to analyse and code interview data, with the resultant categories reported. Approaches to teaching manual clinical skills, in particular scalpel skills, appear to be consistent between university programs in Australia and New Zealand in utilising didactic-style content, demonstration, physical practice on inanimate objects and real skin, and often the use of supplementary audio-visual material. The main reported differences between programs were in methods and processes of practice, with controversy regarding the use of inanimate objects versus real skin for practice. Despite a lack of research and literature surrounding this topic, the approach to teaching is relatively consistent between programs with greatest disparity being the structure and duration of practice. Key issues for teaching staff in teaching manual skills were students' clinical exposure, motivation, levels of anxiety and dexterity.

Exploring the scope of expanding advanced nursing practice in nurse-led clinics: a multiple-case study.

PubMed

Shiu, Ann T Y; Lee, Diana T F; Chau, Janita P C

2012-08-01

This article is a report on a study to explore the development of expanding advanced nursing practice in nurse-led clinics in Hong Kong. Nurse-led clinics serviced by advanced practice nurses, a common international practice, have been adopted in Hong Kong since 1990s. Evaluations consistently show that this practice has good clinical outcomes and contributes to containing healthcare cost. However, similar to the international literature, it remains unclear as to what the elements of good advanced nursing practice are, and which directions Hong Kong should adopt for further development of such practice. A multiple-case study design was adopted with six nurse-led clinics representing three specialties as six case studies, and including two clinics each from continence, diabetes and wound care. Each case had four embedded units of analysis. They included non-participant observation of nursing activities (9 days), nurse interviews (N = 6), doctor interviews (N = 6) and client interviews (N = 12). The data were collected in 2009. Within- and cross-case analyses were conducted. The cross-case analysis demonstrated six elements of good advanced nursing practice in nurse-led clinics, and showed a great potential to expand the practice by reshaping four categories of current boundaries, including community-hospital, wellness-illness, public-private and professional-practice boundaries. From these findings, we suggest a model to advance the scope of advanced nursing practice in nurse-led clinics. The six elements may be applied as audit criteria for evaluation of advanced nursing practice in nurse-led clinics, and the proposed model provides directions for expanding such practice in Hong Kong and beyond. © 2011 Blackwell Publishing Ltd.

Evaluating a standardised clinical assessment tool for pre-registration midwifery students: A cross-sectional survey of midwifery students and midwives in Australia.

PubMed

Morrow, Jane; Biggs, Laura; Stelfox, Sara; Phillips, Diane; McKellar, Lois; McLachlan, Helen

2016-02-01

Assessment of clinical competence is a core component of midwifery education. Clinical assessment tools have been developed to help increase consistency and overcome subjectivity of assessment. The study had two main aims. The first was to explore midwifery students and educators/clinical midwives' views and experiences of a common clinical assessment tool used for all preregistration midwifery programmes in Victoria and the University of South Australia. The second was to assess the need for changes to the tool to align with developments in clinical practice and evidence-based care. A cross-sectional, web-based survey including Likert-type scales and open-ended questions was utilised. Students enrolled in all four entry pathways to midwifery at seven Victorian and one South Australian university and educators/clinical midwives across both states. One hundred and ninety-one midwifery students' and 86 educators/clinical midwives responded. Overall, students and educators/clinical midwives were positive about the Clinical Assessment Tool with over 90% reporting that it covered the necessary midwifery skills. Students and educators/clinical midwives reported high levels of satisfaction with the content of the learning tools. Only 4% of educators/clinical midwives and 6% of students rated the Clinical Assessment Tool as poor overall. Changes to some learning tools were necessary in order to reflect recent practice and evidence. A common clinical assessment tool for evaluating midwifery students' clinical practice may facilitate the provision of consistent, reliable and objective assessment of student skills and competency. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Exploring the acquisition of entry-to-practice competencies by second-degree nursing students during a preceptorship experience.

PubMed

Sedgwick, Monique; Kellett, Peter; Kalischuck, Ruth Grant

2014-03-01

Nursing programs across Canada have begun to implement at an unprecedented rate second-degree nursing programs in response to consumer demands and a nursing shortage. While these types of programs are enjoying considerable popularity among prospective students and employers, it is imperative that nursing programs assess their graduates' ability to meet Registered Nursing entry-to-practice competencies (ETCs). This study sought to determine if second-degree undergraduate nursing students achieved the entry-to-practice competencies established by the provincial regulatory body for registered nurses of Alberta, Canada. The study took place in southern Alberta, Canada as the first cohort of second-degree undergraduate nursing students were completing the final practice course for the program. In this exploratory study, quantitative and qualitative data generation approaches were used. Quantitative data were collected using the nursing program's standardized Clinical Evaluation Tool which is mapped to the 119 ETCs established by the regulatory body. Qualitative data were generated by conducting focus group interviews with students, faculty advisors, and preceptors. A convenience sample consisting of both male and female students (n=14) submitted their mid-term and final clinical evaluations for inclusion in the dataset. Thirteen preceptors submitted mid-term and final clinical evaluations. Three students, three faculty advisors, and two preceptors participated in focus group interviews. At mid-term, statistically significant differences were noted on 31% of the indicators within the clinical evaluation tool between students and preceptors with preceptors consistently ranking students higher than the students' ratings of their performance. Student and preceptor ratings of students' clinical performance were more consistent on the final evaluation. However, where there were differences, preceptors rated students higher than student ratings. Qualitative data analysis suggests that the concept of competence is complex and multifaceted and understood differently by students, preceptors, and advisors. The findings of this study suggest that there is ambiguity among second-degree students, preceptors and faculty advisors surrounding the concept of competence. In order to develop an understanding of competence, nursing program administrators must encourage faculty advisors, preceptors and students to engage in a discussion at the outset of the preceptored practice experience in regard to what is meant by competence within various practice setting. Further, we suggest nursing programs in collaboration with their clinical partners and re-examine their practice evaluation tools to determine the degree to which they are sensitive to the clinical practice context. Copyright © 2013 Elsevier Ltd. All rights reserved.

A randomised controlled trial of clinics in secondary schools for adolescents with asthma.

PubMed Central

Salisbury, Chris; Francis, Caia; Rogers, Chris; Parry, Kate; Thomas, Huw; Chadwick, Stephanie; Turton, Pat

2002-01-01

AIM: To compare a nurse-led clinic in schools versus care in general practice for adolescents with asthma. DESIGN OF STUDY: Randomised controlled trial in four schools; parallel observational study in two schools. SETTING: Six comprehensive schools. METHOD: In the randomised trial, pupils were invited to attend asthma review at a nurse-led clinic either in school, or in general practice. The parallel observational study compared pupils invited to practice care within and outside the randomised trial. Primary outcome measures were attendance for asthma review, symptom control, and quality of life. Secondary outcomes were knowledge, attitudes, inhaler technique, use of steroids, school absence, peak flow rate, preference for future care, health service utilisation, and costs. RESULTS: School clinic pupils were more likely to attend an asthma review than those randomised to practice care (90.8% versus 51.0% overall [P < 0.001, not consistent across schools]). No differences were observed in symptom control (P = 0.42) or quality of life (P = 0.63). Pupils attending school clinics had greater knowledge of asthma (difference = +0.38, 95% CI = 0.19 to 0.56), more positive attitudes (difference = +0.21, 95% CI = 0.05 to 0.36), and better inhaler technique (P < 0.001, not consistent across all schools). No differences were observed in school absence or peak flow rate. A majority (63%) of those who had received care at school preferred this model in future. Median costs of providing care at school and at the practice were 32.10 Pounds and 19.80 Pounds, respectively. No differences were observed between the groups in the observational comparison on any outcome. CONCLUSIONS: The schools asthma clinic increased uptake of asthma reviews. There were improvements in various process measures, but not in clinical outcomes. PMID:12528584

Promoting physical therapists' of research evidence to inform clinical practice: part 1--theoretical foundation, evidence, and description of the PEAK program.

PubMed

Tilson, Julie K; Mickan, Sharon

2014-06-25

There is a need for theoretically grounded and evidence-based interventions that enhance the use of research evidence in physical therapist practice. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists' integration of research evidence into clinical decision-making. The pedagogical foundations for the PEAK educational program include Albert Bandura's social cognitive theory and Malcolm Knowles's adult learning theory. Additionally, two complementary frameworks of knowledge translation, the Promoting Action on Research Implementation in Health Services (PARiHS) and Knowledge to Action (KTA) Cycle, were used to inform the organizational elements of the program. Finally, the program design was influenced by evidence from previous attempts to facilitate the use of research in practice at the individual and organizational levels. The 6-month PEAK program consisted of four consecutive and interdependent components. First, leadership support was secured and electronic resources were acquired and distributed to participants. Next, a two-day training workshop consisting of didactic and small group activities was conducted that addressed the five steps of evidence based practice. For five months following the workshop, participants worked in small groups to review and synthesize literature around a group-selected area of common clinical interest. Each group contributed to the generation of a "Best Practices List" - a list of locally generated, evidence-based, actionable behaviors relevant to the groups' clinical practice. Ultimately, participants agreed to implement the Best Practices List in their clinical practice. This, first of two companion papers, describes the underlying pedagogical theories, knowledge translation frameworks, and research evidence used to derive the PEAK program - an educational program designed to promote the use of research evidence to inform physical therapist practice. The four components of the program are described in detail. The companion paper reports the results of a mixed methods feasibility analysis of this complex educational intervention.

Through the eyes of the student: Best practices in clinical facilitation.

PubMed

Muthathi, Immaculate S; Thurling, Catherine H; Armstrong, Susan J

2017-08-28

Clinical facilitation is an essential part of the undergraduate nursing curriculum. A number of studies address the issue of clinical facilitation in South Africa, but there remains a lack of knowledge and understanding regarding what students perceive as best practice in clinical facilitation of their learning. To determine what type of clinical facilitation undergraduate students believe should be offered by clinical facilitators (nurse educators, professional nurses and clinical preceptors) in the clinical area in order to best facilitate their learning. A qualitative, exploratory and descriptive study was conducted. Purposive sampling was performed to select nursing students from the second, third and fourth year of studies from a selected nursing education institution in Johannesburg. The sampling resulted in one focus group for each level of nursing, namely second, third and fourth year nursing students. Interviews were digitally recorded and transcribed verbatim, thematic data analysis was used and trustworthiness was ensured by applying credibility, dependability, confirmability and transferability. The data revealed that participants differentiated between best practices in clinical facilitation in the clinical skills laboratory and clinical learning environment. In the clinical skills laboratory, pre-contact preparation, demonstration technique and optimising group learning were identified as best practices. In the clinical learning environment, a need for standardisation of procedures in simulation and practice, the allocation and support for students also emerged. There is a need for all nurses involved in undergraduate nursing education to reflect on how they approach clinical facilitation, in both clinical skills laboratory and clinical learning environment. There is also a need to improve consistency in clinical practices between the nursing education institution and the clinical learning environment so as to support students' adaptation to clinical practice.

Oral hygiene teaching in clinical activities at the Department of Dentistry of Dakar (Senegal).

PubMed

Massamba, Diouf; Adama, Faye; Daouda, Faye; Daouda, Cissé; Lo Cheikh, M M

2010-06-01

The aim of this study was to assess the attitudes and practices of students related to oral hygiene teaching by mean of a questionnaire submitted to patients attending the clinics of the Department of Dentistry of Dakar. A KPC study (Knowledge, Practices and Coverage) focusing on dental students was conducted and consists on a interview of 295 patients. The socio-demographic and brushing method variables involved the patients. While those related to attitudes and practices regarding oral hygiene teaching concerned only students. The tests at the univariate and multivariate analysis by logistic regression were significant when P < 0.05. The study population consisted of 48.5% of men, 76.6% were adults. 32.9% of patients came from the Conservative Dentistry and Endodontic (CDE) clinic and 5.4% of them from Orthodontic clinic. For 52.2% of patients, no prophylactic measure was laid and the link with the proper brushing technique of patients was significant (OR = 4.4). Using supports at time of oral hygiene teaching was respected for 17.4% of cases. It was associated with proper brushing technique even after adjustment. The attitudes and practices of students in Dentistry Department of Dakar in relation to oral hygiene teaching deserves more vigilant in watching over the prophylactic care and using supports during oral hygiene teaching.

Understanding Clinic Practices for Human Papilloma Virus Vaccination Series Completion in Clinics That Provide Primary Care: Survey of Clinic Managers in Iowa.

PubMed

Askelson, Natoshia M; Edmonds, Stephanie W; Momany, Elizabeth T; Tegegne, Mesay A

2016-07-01

Rates for human papilloma virus (HPV) vaccination are low across the United States. Evidence-based-practices to increase immunization coverage have been recommended by public health organizations, yet many primary care clinics do not follow these practices. The purpose of this study was to examine if primary care clinics use these best practices to promote completion of the HPV vaccine series for their adolescent patients. Understanding the prevalence of evidence-based immunization strategies is key to increasing vaccination coverage. We mailed 914 surveys to clinic managers of clinics that provide primary care in Iowa. The survey content was based on immunization strategies related to clinic practice and policies that have been proven effective to promote the completion of the HPV vaccination series. Survey responses from 127 clinics were used in the final analysis. Most clinics always used the state's immunization information system to record HPV vaccinations (89.4%). Over a quarter of clinics (27.6%) did not use any type of reminder or recall system to alert parents or providers that an HPV vaccine was due, and 35.0% did not give the vaccine at sick visits. Clinics need to focus more on the recommended logistics and processes to ensure that patients receive the entire HPV vaccination series. Survey results indicate that clinics are not consistently implementing the recommended best practices to ensure that vaccination series are completed.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2011-06-01

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery. © 2011 Blackwell Publishing Asia Pty Ltd.

Isavuconazole Concentration in Real-world Practice: Consistency with Results from Clinical Trials.

PubMed

Andes, David; Kovanda, Laura; Desai, A; Kitt, Theresa; Zhao, M; Walsh, Thomas J

2018-05-07

Clinical use of voriconazole, posaconazole, and itraconazole revealed the need for therapeutic drug monitoring (TDM) of plasma concentrations of these antifungal agents. This need for TDM was not evident from clinical trials of these drugs. In order to establish if this requirement also applies to isavuconazole, we examined the plasma concentrations of 283 samples receiving isavuconazole in clinical practice and compared the values to those from clinical trials. The concentration distributions from real-world use and clinical trials were nearly identical (>1 μg/mL in 90% of patients). These findings suggest that routine TDM may not be required for isavuconazole in most instances. Copyright © 2018 American Society for Microbiology.

Safe clinical practice for patients hospitalised in a suicidal crisis: a study protocol for a qualitative case study.

PubMed

Berg, Siv Hilde; Rørtveit, Kristine; Walby, Fredrik A; Aase, Karina

2017-01-27

Suicide prevention in psychiatric care is arguably complex and incompletely understood as a patient safety issue. A resilient healthcare approach provides perspectives through which to understand this complexity by understanding everyday clinical practice. By including suicidal patients and healthcare professionals as sources of knowledge, a deeper understanding of what constitutes safe clinical practice can be achieved. This planned study aims to adopt the perspective of resilient healthcare to provide a deeper understanding of safe clinical practice for suicidal patients in psychiatric inpatient care. It will describe the experienced components and conditions of safe clinical practice and the experienced practice of patient safety. The study will apply a descriptive case study approach consisting of qualitative semistructured interviews and focus groups. The data sources are hospitalised patients in a suicidal crisis and healthcare professionals in clinical practice. This study was approved by the Regional Ethics Committee (2016/34). The results will be disseminated through scientific articles, a PhD dissertation, and national and international conferences. These findings can generate knowledge to be integrated into the practice of safety for suicidal inpatients in Norway and to improve the feasibility of patient safety measures. Theoretical generalisations can be drawn regarding safe clinical practice by taking into account the experiences of patients and healthcare professionals. Thus, this study can inform the conceptual development of safe clinical practice for suicidal patients. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Implementing guidelines: Proposed definitions of neuropsychology services in pediatric oncology.

PubMed

Baum, Katherine T; Powell, Stephanie K; Jacobson, Lisa A; Gragert, Marsha N; Janzen, Laura A; Paltin, Iris; Rey-Casserly, Celiane M; Wilkening, Greta N

2017-08-01

Several organizations have published guidelines for the neuropsychological care of survivors of childhood cancer. However, there is limited consensus in how these guidelines are applied. The model of neuropsychology service delivery is further complicated by the variable terminology used to describe recommended services. In an important first step to translate published guidelines into clinical practice, this paper proposes definitions for specific neuropsychological processes and services, with the goal of facilitating consistency across sites to foster future clinical program development and to clarify clinical practice guidelines. © 2017 Wiley Periodicals, Inc.

Exploring Organizational Barriers to Strengthening Clinical Supervision of Psychiatric Nursing Staff: A Longitudinal Controlled Intervention Study.

PubMed

Gonge, Henrik; Buus, Niels

2016-05-01

This article reports findings from a longitudinal controlled intervention study of 115 psychiatric nursing staff. The twofold objective of the study was: (a) To test whether the intervention could increase clinical supervision participation and effectiveness of existing supervision practices, and (b) To explore organizational constraints to implementation of these strengthened practices. Questionnaire responses and registration of participation in clinical supervision were registered prior and subsequent to the intervention consisting of an action learning oriented reflection on staff's existing clinical supervision practices. Major organizational changes in the intervention group during the study period obstructed the implementation of strengthened clinical supervision practices, but offered an opportunity for studying the influences of organizational constraints. The main findings were that a) diminishing experience of social support from colleagues was associated with reduced participation in clinical supervision, while b) additional quantitative demands were associated with staff reporting difficulties finding time for supervision. This probably explained a negative development in the experienced effectiveness of supervision. It is concluded that organizational support is an imperative for implementation of clinical supervision.

Decreasing barriers for nurse practitioner social entrepreneurship.

PubMed

Sharp, Dayle B; Monsivais, Diane

2014-10-01

To describe difficulties associated with the business-related aspects of practice in role transition of rural nurse practitioners (NPs), and to give practice implications. This focused ethnographic study derived data from semi-structured interviews. Participants provided information about rural NP practice ownership and barriers. The sample consisted of 24 rural NPs living throughout the United States. The majority were 51-60 years of age (45%) and females (93%) who had been in rural practice for 1 to over 20 years. NP social entrepreneurs experience difficulties related to scope of practice, business skills, and role conflict. To decrease barriers for NP clinic ownership and management, NPs need to receive education related to financing a rural practice, legal/regulatory practices, strategic planning, leadership, and clinic management. ©2014 American Association of Nurse Practitioners.

Birth Control in Clinical Trials

PubMed Central

Stewart, J.; Beyer, B. K.; Chadwick, K.; De Schaepdrijver, L.; Desai, M.; Enright, B.; Foster, W.; Hui, J. Y.; Moffat, G. J.; Tornesi, B.; Van Malderen, K.; Wiesner, L.; Chen, C. L.

2015-01-01

The Health and Environmental Sciences Institute (HESI) Developmental and Reproductive Toxicology Technical Committee sponsored a pharmaceutical industry survey on current industry practices for contraception use during clinical trials. The objectives of the survey were to improve our understanding of the current industry practices for contraception requirements in clinical trials, the governance processes set up to promote consistency and/or compliance with contraception requirements, and the effectiveness of current contraception practices in preventing pregnancies during clinical trials. Opportunities for improvements in current practices were also considered. The survey results from 12 pharmaceutical companies identified significant variability among companies with regard to contraception practices and governance during clinical trials. This variability was due primarily to differences in definitions, areas of scientific uncertainty or misunderstanding, and differences in company approaches to enrollment in clinical trials. The survey also revealed that few companies collected data in a manner that would allow a retrospective understanding of the reasons for failure of birth control during clinical trials. In this article, suggestions are made for topics where regulatory guidance or scientific publications could facilitate best practice. These include provisions for a pragmatic definition of women of childbearing potential, guidance on how animal data can influence the requirements for male and female birth control, evidence-based guidance on birth control and pregnancy testing regimes suitable for low- and high-risk situations, plus practical methods to ascertain the risk of drug-drug interactions with hormonal contraceptives. PMID:27042398

Evidence-based algorithm for heparin dosing before cardiopulmonary bypass. Part 1: Development of the algorithm.

PubMed

McKinney, Mark C; Riley, Jeffrey B

2007-12-01

The incidence of heparin resistance during adult cardiac surgery with cardiopulmonary bypass has been reported at 15%-20%. The consistent use of a clinical decision-making algorithm may increase the consistency of patient care and likely reduce the total required heparin dose and other problems associated with heparin dosing. After a directed survey of practicing perfusionists regarding treatment of heparin resistance and a literature search for high-level evidence regarding the diagnosis and treatment of heparin resistance, an evidence-based decision-making algorithm was constructed. The face validity of the algorithm decisive steps and logic was confirmed by a second survey of practicing perfusionists. The algorithm begins with review of the patient history to identify predictors for heparin resistance. The definition for heparin resistance contained in the algorithm is an activated clotting time < 450 seconds with > 450 IU/kg heparin loading dose. Based on the literature, the treatment for heparin resistance used in the algorithm is anti-thrombin III supplement. The algorithm seems to be valid and is supported by high-level evidence and clinician opinion. The next step is a human randomized clinical trial to test the clinical procedure guideline algorithm vs. current standard clinical practice.

In defense of clinical conferences in clinical nursing education.

PubMed

Vezeau, Toni M

2016-01-01

Clinical conferencing has been a consistent feature of clinical education, but the current clinical education environment poses many challenges to its continuance. The paper raises concern regarding the current state of clinical conferencing as part of clinical practice education in nursing. This topic is of great concern, but has there is little direction for clinical educators. The paper reviews the literature on conferencing and recommends avenues for future research. Copyright © 2015 Elsevier Ltd. All rights reserved.

Applying health information technology and team-based care to residency education.

PubMed

Brown, Kristy K; Master-Hunter, Tara A; Cooke, James M; Wimsatt, Leslie A; Green, Lee A

2011-01-01

Training physicians capable of practicing within the Patient-centered Medical Home (PCMH) is an emerging area of scholarly inquiry within residency education. This study describes an effort to integrate PCMH principles into teaching practices within a university-based residency setting and evaluates the effect on clinical performance. Using participant feedback and clinical data extracted from an electronic clinical quality management system, we retrospectively examined performance outcomes at two family medicine residency clinics over a 7-year period. Instructional approaches were identified and clinical performance patterns analyzed. Alumni ratings of the practice-based curriculum increased following institution of the PCMH model. Clinical performance outcomes indicated improvements in the delivery of clinical care to patients. Implementation of instructional methodologies posed some challenges to residency faculty, particularly in development of consistent scheduling of individualized feedback sessions. Residents required the greatest support and guidance in managing point-of-care clinical reminders during patient encounters. Teaching practices that take into consideration the integration of team-based care and use of electronic health technologies can successfully be used to deliver residency education in the context of the PCMH model. Ongoing assessment provides important information to residency directors and faculty in support of improving the quality of clinical instruction.

Clinical reasoning of Filipino physical therapists: Experiences in a developing nation.

PubMed

Rotor, Esmerita R; Capio, Catherine M

2018-03-01

Clinical reasoning is essential for physical therapists to engage in the process of client care, and has been known to contribute to professional development. The literature on clinical reasoning and experiences have been based on studies from Western and developed nations, from which multiple influencing factors have been found. A developing nation, the Philippines, has distinct social, economic, political, and cultural circumstances. Using a phenomenological approach, this study explored experiences of Filipino physical therapists on clinical reasoning. Ten therapists working in three settings: 1) hospital; 2) outpatient clinic; and 3) home health were interviewed. Major findings were: a prescription-based referral system limited clinical reasoning; procedural reasoning was a commonly experienced strategy while diagnostic and predictive reasoning were limited; factors that influenced clinical reasoning included practice setting and the professional relationship with the referring physician. Physical therapists' responses suggested a lack of autonomy in practice that appeared to stifle clinical reasoning. Based on our findings, we recommend that the current regulations governing PT practice in the Philippines may be updated, and encourage educators to strengthen teaching approaches and strategies that support clinical reasoning. These recommendations are consistent with the global trend toward autonomous practice.

Communicating their individual results to participants in an environmental exposure study: Insights from clinical ethics

DOE Office of Scientific and Technical Information (OSTI.GOV)

Deck, W.; Kosatsky, T.

1999-02-01

A study measuring the uptake of chemical contaminants among sport fishers who consume fish caught in the St. Lawrence river is currently being conducted in Montreal, Canada. In this study, blood, hair, and urine collected from local sport fishers is being tested for heavy metals and persistent organochlorine chemicals. The objective of this study was to formulate a framework for determining what information to communicate to individual subjects of a study measuring biomarkers of exposure, consistent with the principles of ethical clinical and research practice. Methods consisted of review of the scope of environmental exposure studies, including the use ofmore » biomarker measurement in clinical medicine and environmental research and the relevant principles of clinical ethics and research practice. An exposure biomarker study is designed to elucidate constitutional, behavioral, and environmental determinants of tissue concentrations of exogenous substances. Ethical clinical and research practice, aiming to maximize autonomy and beneficence and to minimize harm, requires that study findings concerning the determinants of exposure be communicated to study participants. In addition, investigators should reference clinical action levels beyond which individual biomarker results are routinely communicated to participants. When biomarkers have no known relation to risk, or when levels fall below action levels, it may be preferable not co communicate individual results, if this arrangement has been formalized at the time of informed consent.« less

A Model of Teaching-Learning Transactions in Generalist-Specialist Consultations

ERIC Educational Resources Information Center

Shershneva, Marianna B.; Carnes, Molly; Bakken, Lori L.

2006-01-01

Introduction: A new paradigm in continuing medical education is characterized by emphasis on physicians' learning in practice. Consistent with this paradigm, our study examined a subset of clinical practice--generalist-specialist consultations--from an educational perspective. Methods: We applied the grounded-theory method with semistructured…

Birth Control in Clinical Trials: Industry Survey of Current Use Practices, Governance, and Monitoring.

PubMed

Stewart, J; Breslin, W J; Beyer, B K; Chadwick, K; De Schaepdrijver, L; Desai, M; Enright, B; Foster, W; Hui, J Y; Moffat, G J; Tornesi, B; Van Malderen, K; Wiesner, L; Chen, C L

2016-03-01

The Health and Environmental Sciences Institute (HESI) Developmental and Reproductive Toxicology Technical Committee sponsored a pharmaceutical industry survey on current industry practices for contraception use during clinical trials. The objectives of the survey were to improve our understanding of the current industry practices for contraception requirements in clinical trials, the governance processes set up to promote consistency and/or compliance with contraception requirements, and the effectiveness of current contraception practices in preventing pregnancies during clinical trials. Opportunities for improvements in current practices were also considered. The survey results from 12 pharmaceutical companies identified significant variability among companies with regard to contraception practices and governance during clinical trials. This variability was due primarily to differences in definitions, areas of scientific uncertainty or misunderstanding, and differences in company approaches to enrollment in clinical trials. The survey also revealed that few companies collected data in a manner that would allow a retrospective understanding of the reasons for failure of birth control during clinical trials. In this article, suggestions are made for topics where regulatory guidance or scientific publications could facilitate best practice. These include provisions for a pragmatic definition of women of childbearing potential, guidance on how animal data can influence the requirements for male and female birth control, evidence-based guidance on birth control and pregnancy testing regimes suitable for low- and high-risk situations, plus practical methods to ascertain the risk of drug-drug interactions with hormonal contraceptives.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE.

PubMed

Mechanick, Jeffrey I; Pessah-Pollack, Rachel; Camacho, Pauline; Correa, Ricardo; Figaro, M Kathleen; Garber, Jeffrey R; Jasim, Sina; Pantalone, Kevin M; Trence, Dace; Upala, Sikarin

2017-08-01

Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment. AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.

Quality management of clinical-practical instruction for Practical Year medical students in Germany - proposal for a catalogue of criteria from the German Society of Medical Education.

PubMed

Raes, Patricia; Angstwurm, Matthias; Berberat, Pascal; Kadmon, Martina; Rotgans, Jerome; Streitlein-Böhme, Irmgard; Burckhardt, Gerhard; Fischer, Martin R

2014-01-01

Amended in 2013, the current version of the German Medical Licensure Regulation contains structural specifications that are also required of non-university institutions involved in Practical Year clinical training. The criteria are worded in relatively general terms. Furthermore, not all of the structural specifications can be readily applied to every subject area. In order to ensure commensurability in Practical Year instruction in Germany, not least in light of recently introduced Practical Year mobility, it is necessary to define consistent quality criteria for Practical Year training. The authors therefore propose a catalogue of criteria for the quality management process in Practical Year instruction facilities. In January 2014, the board of directors of the German Society for Medical Education decided to establish a committee comprised of representatives from various German medical faculties. In a process similar to the Delphi methodology, the group developed criteria for structure, process and outcome quality in Practical Year training in Germany. The criteria developed for structure, process and outcome quality apply to Practical Year training in academic teaching hospitals and university medical centres. Furthermore, modalities for review are proposed. The present catalogue of criteria is intended to contribute to the formation of a basis for the most consistent quality standards possible for Practical Year instruction in Germany.

Quality assurance and the need to evaluate interventions and audit programme outcomes.

PubMed

Zhao, Min; Vaartjes, Ilonca; Klipstein-Grobusch, Kerstin; Kotseva, Kornelia; Jennings, Catriona; Grobbee, Diederick E; Graham, Ian

2017-06-01

Evidence-based clinical guidelines provide standards for the provision of healthcare. However, these guidelines have been poorly implemented in daily practice. Clinical audit is a quality improvement tool to promote quality of care in daily practice and to improve outcomes through the systematic review of care delivery and implementation of changes. A major priority in the management of subjects with cardiovascular disease (CVD) management is secondary prevention by controlling cardiovascular risk factors and providing appropriate medical treatment. Clinical audits can be applied to monitor modifiable risk factors and evaluate quality improvements of CVD management in daily practice. Existing clinical audits have provided an overview of the burden of risk factors in subjects with CVD and reflect real-world risk factor recording and management. However, consistent and representative data from clinic audits are still insufficient to fully monitor quality improvement of CVD management. Data are lacking in particular from low- and middle-income countries, limiting the evaluation of CVD management quality by clinical audit projects in many settings. To support the development of clinical standards, monitor daily practice performance, and improve quality of care in CVD management at national and international levels, more widespread clinical audits are warranted.

Evidence-based Practices Addressed in Community-based Children’s Mental Health Clinical Supervision

PubMed Central

Accurso, Erin C.; Taylor, Robin M.; Garland, Ann F.

2013-01-01

Context Clinical supervision is the principal method of training for psychotherapeutic practice, however there is virtually no research on supervision practice in community settings. Of particular interest is the role supervision might play in facilitating implementation of evidence-based (EB) care in routine care settings. Objective This study examines the format and functions of clinical supervision sessions in routine care, as well as the extent to which supervision addresses psychotherapeutic practice elements common to EB care for children with disruptive behavior problems, who represent the majority of patients served in publicly-funded routine care settings. Methods Supervisors (n=7) and supervisees (n=12) from four publicly-funded community-based child mental health clinics reported on 130 supervision sessions. Results Supervision sessions were primarily individual in-person meetings lasting one hour. The most common functions included case conceptualization and therapy interventions. Coverage of practice elements common to EB treatments was brief. Discussion Despite the fact that most children presenting to public mental health services are referred for disruptive behavior problems, supervision sessions are infrequently focused on practice elements consistent with EB treatments for this population. Supervision is a promising avenue through which training in EB practices could be supported to improve the quality of care for children in community-based “usual care” clinics. PMID:24761163

How do we know what makes for "best practice" in clinical supervision for psychological therapists? A content analysis of supervisory models and approaches.

PubMed

Simpson-Southward, Chloe; Waller, Glenn; Hardy, Gillian E

2017-11-01

Clinical supervision for psychotherapies is widely used in clinical and research contexts. Supervision is often assumed to ensure therapy adherence and positive client outcomes, but there is little empirical research to support this contention. Regardless, there are numerous supervision models, but it is not known how consistent their recommendations are. This review aimed to identify which aspects of supervision are consistent across models, and which are not. A content analysis of 52 models revealed 71 supervisory elements. Models focus more on supervisee learning and/or development (88.46%), but less on emotional aspects of work (61.54%) or managerial or ethical responsibilities (57.69%). Most models focused on the supervisee (94.23%) and supervisor (80.77%), rather than the client (48.08%) or monitoring client outcomes (13.46%). Finally, none of the models were clearly or adequately empirically based. Although we might expect clinical supervision to contribute to positive client outcomes, the existing models have limited client focus and are inconsistent. Therefore, it is not currently recommended that one should assume that the use of such models will ensure consistent clinician practice or positive therapeutic outcomes. There is little evidence for the effectiveness of supervision. There is a lack of consistency in supervision models. Services need to assess whether supervision is effective for practitioners and patients. Copyright © 2017 John Wiley & Sons, Ltd.

Managing the clinical setting for best nursing practice: a brief overview of contemporary initiatives.

PubMed

Henderson, Amanda; Winch, Sarah

2008-01-01

Leadership strategies are important in facilitating the nursing profession to reach their optimum standards in the practice environment. To compare and contrast the central tenets of contemporary quality initiatives that are commensurate with enabling the environment so that best practice can occur. Democratic leadership, accessible and relevant education and professional development, the incorporation of evidence into practice and the ability of facilities to be responsive to change are core considerations for the successful maintenance of practice standards that are consistent with best nursing practice. While different concerns of management drive the adoption of contemporary approaches, there are many similarities in the how these approaches are translated into action in the clinical setting. Managers should focus on core principles of professional nursing that add value to practice rather than business processes.

Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study.

PubMed

Eccles, Martin P; Hrisos, Susan; Francis, Jill J; Stamp, Elaine; Johnston, Marie; Hawthorne, Gillian; Steen, Nick; Grimshaw, Jeremy M; Elovainio, Marko; Presseau, Justin; Hunter, Margaret

2011-06-09

Type 2 diabetes is an increasingly prevalent chronic illness and an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of primary care teams. This study aimed to: investigate theoretically-based organisational, team, and individual factors determining the multiple behaviours needed to manage diabetes; and identify multilevel determinants of different diabetes management behaviours and potential interventions to improve them. This paper describes the instrument development, study recruitment, characteristics of the study participating practices and their constituent healthcare professionals and administrative staff and reports descriptive analyses of the data collected. The study was a predictive study over a 12-month period. Practices (N = 99) were recruited from within the UK Medical Research Council General Practice Research Framework. We identified six behaviours chosen to cover a range of clinical activities (prescribing, non-prescribing), reflect decisions that were not necessarily straightforward (controlling blood pressure that was above target despite other drug treatment), and reflect recommended best practice as described by national guidelines. Practice attributes and a wide range of individually reported measures were assessed at baseline; measures of clinical outcome were collected over the ensuing 12 months, and a number of proxy measures of behaviour were collected at baseline and at 12 months. Data were collected by telephone interview, postal questionnaire (organisational and clinical) to practice staff, postal questionnaire to patients, and by computer data extraction query. All 99 practices completed a telephone interview and responded to baseline questionnaires. The organisational questionnaire was completed by 931/1236 (75.3%) administrative staff, 423/529 (80.0%) primary care doctors, and 255/314 (81.2%) nurses. Clinical questionnaires were completed by 326/361 (90.3%) primary care doctors and 163/186 (87.6%) nurses. At a practice level, we achieved response rates of 100% from clinicians in 40 practices and > 80% from clinicians in 67 practices. All measures had satisfactory internal consistency (alpha coefficient range from 0.61 to 0.97; Pearson correlation coefficient (two item measures) 0.32 to 0.81); scores were generally consistent with good practice. Measures of behaviour showed relatively high rates of performance of the six behaviours, but with considerable variability within and across the behaviours and measures. We have assembled an unparalleled data set from clinicians reporting on their cognitions in relation to the performance of six clinical behaviours involved in the management of people with one chronic disease (diabetes mellitus), using a range of organisational and individual level measures as well as information on the structure of the practice teams and across a large number of UK primary care practices. We would welcome approaches from other researchers to collaborate on the analysis of this data.

Building a Knowledge to Action Program in Stroke Rehabilitation.

PubMed

Janzen, Shannon; McIntyre, Amanda; Richardson, Marina; Britt, Eileen; Teasell, Robert

2016-09-01

The knowledge to action (KTA) process proposed by Graham et al (2006) is a framework to facilitate the development and application of research evidence into clinical practice. The KTA process consists of the knowledge creation cycle and the action cycle. The Evidence Based Review of Stroke Rehabilitation is a foundational part of the knowledge creation cycle and has helped guide the development of best practice recommendations in stroke. The Rehabilitation Knowledge to Action Project is an audit-feedback process for the clinical implementation of best practice guidelines, which follows the action cycle. The objective of this review was to: (1) contextualize the Evidence Based Review of Stroke Rehabilitation and Rehabilitation Knowledge to Action Project within the KTA model and (2) show how this process led to improved evidence-based practice in stroke rehabilitation. Through this process, a single centre was able to change clinical practice and promote a culture that supports the use of evidence-based practices in stroke rehabilitation.

Ireland and medical research with minors: some medico-legal aspects.

PubMed

Sheikh, Asim A

2008-07-01

The practice of medical research with minors in Ireland consist of practices pertaining to therapeutic and non-therapeutic medical research. Clinical trials (a category of therapeutic research), is governed by legislation. However, any other therapeutic research (non-clinical trials research) and non-therapeutic research, e.g. observational medical research such as a longitudinal study of children or non-therapeutic research such as blood sample collection for analysis of cause of disease, are unregulated by legislation. This, article will outline and describe some of the medico-legal issues involved in both types of research and will comment on matters such as what national law exists, how the directive on good clinical practice has been implemented, what guidelines, if any, exist.

Promoting physical therapists’ of research evidence to inform clinical practice: part 1 - theoretical foundation, evidence, and description of the PEAK program

PubMed Central

2014-01-01

Background There is a need for theoretically grounded and evidence-based interventions that enhance the use of research evidence in physical therapist practice. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists’ integration of research evidence into clinical decision-making. The pedagogical foundations for the PEAK educational program include Albert Bandura’s social cognitive theory and Malcolm Knowles’s adult learning theory. Additionally, two complementary frameworks of knowledge translation, the Promoting Action on Research Implementation in Health Services (PARiHS) and Knowledge to Action (KTA) Cycle, were used to inform the organizational elements of the program. Finally, the program design was influenced by evidence from previous attempts to facilitate the use of research in practice at the individual and organizational levels. Discussion The 6-month PEAK program consisted of four consecutive and interdependent components. First, leadership support was secured and electronic resources were acquired and distributed to participants. Next, a two-day training workshop consisting of didactic and small group activities was conducted that addressed the five steps of evidence based practice. For five months following the workshop, participants worked in small groups to review and synthesize literature around a group-selected area of common clinical interest. Each group contributed to the generation of a “Best Practices List” - a list of locally generated, evidence-based, actionable behaviors relevant to the groups’ clinical practice. Ultimately, participants agreed to implement the Best Practices List in their clinical practice. Summary This, first of two companion papers, describes the underlying pedagogical theories, knowledge translation frameworks, and research evidence used to derive the PEAK program – an educational program designed to promote the use of research evidence to inform physical therapist practice. The four components of the program are described in detail. The companion paper reports the results of a mixed methods feasibility analysis of this complex educational intervention. PMID:24965501

Dichotomy between theory and practice in chest radiography and its impact on students.

PubMed

Botwe, Benard O; Arthur, Lawrence; Tenkorang, Michael K K; Anim-Sampong, Samuel

2017-06-01

It is important that theory is synchronous with clinical practices that students engage in. Lack of congruence between theory and practice presents serious problems to students. This study was therefore conducted to determine if there was a theory-practice gap in chest radiography during clinical rotations, and any associated causes and effects on radiography students. A descriptive survey design was used to conduct this study from 2 February to 27 July 2014. A semi-structured questionnaire consisting of open- and close-ended questions was used to purposively collect data from 26 radiography students in Ghana who had completed theory lessons in chest radiography and had either completed or were undertaking clinical rotations in chest radiography. Twenty-five (96%) respondents indicated the presence of theory-practice gap in chest radiography during clinical rotations, where differences between theory and clinical practice were observed. Lack of working materials 16 (62%), heavy workload 14 (54%), equipment breakdowns 14 (54%) and supervisory factors 11 (43%) were identified as the causes. Many students (81%) experienced diverse adverse effects such as confusion 10 (38%), poor performance during clinical examinations 6 (23%) and entire loss of interest in the professional training 1 (4%) of this dichotomy. Dichotomy between theory and practice found in chest radiography has diverse adverse effects on students. Regular feedback on the quality of clinical practice received by students should be encouraged to determine the existence of any gaps between theory and practice in order to promote effective clinical rotation programmes in radiography. © 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.

Clinical PhD graduate student views of their scientist-practitioner training.

PubMed

VanderVeen, Joseph W; Reddy, L Felice; Veilleux, Jennifer C; January, Alicia M; DiLillo, David

2012-09-01

The goal of the scientist-practitioner (S-P) training model is to produce clinical psychologists equipped to integrate and utilize both science and practice in the clinical and research domains. However, much has been written regarding the possible shortcomings of S-P training and whether clinical psychology graduate students are actually gaining the knowledge and skills to integrate science and practice during graduate training and beyond (Chang, Lee, & Hargreaves, 2008; Gelso, 2006; Merlo, Collins, & Bernstein, 2008; Phillips, 1993). As such, the present study assessed ratings of satisfaction, perception of ability, and use of the S-P training model within 653 clinical psychology graduate students enrolled in programs that are members of the Council of University Directors of Clinical Psychology. Findings suggest that students are consistently trained in the integration of science and practice and have confidence in their abilities to apply the S-P integration to research and clinical work. However, despite understanding the ways in which science can influence practice, over one third of students reported that they rarely use science-based decisions when informing clients of the clinical services they will be providing. The implications of these results support the need for a more detailed evaluation of clinical psychology graduate students as well as the use of research-informed practice and the process of providing clients with information they need to make informed choices about treatment. © 2012 Wiley Periodicals, Inc.

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents

DOE Office of Scientific and Technical Information (OSTI.GOV)

Burmeister, Jay, E-mail: burmeist@karmanos.org; Chen, Zhe; Chetty, Indrin J.

Purpose: The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. Methods and Materials: The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. Results: The newmore » curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. Conclusions: The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint.« less

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents.

PubMed

Burmeister, Jay; Chen, Zhe; Chetty, Indrin J; Dieterich, Sonja; Doemer, Anthony; Dominello, Michael M; Howell, Rebecca M; McDermott, Patrick; Nalichowski, Adrian; Prisciandaro, Joann; Ritter, Tim; Smith, Chadd; Schreiber, Eric; Shafman, Timothy; Sutlief, Steven; Xiao, Ying

2016-07-15

The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. The new curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

A competency-based approach to nurses' continuing education for clinical reasoning and leadership through reflective practice in a care situation.

PubMed

Goudreau, Johanne; Pepin, Jacinthe; Larue, Caroline; Dubois, Sylvie; Descôteaux, Renée; Lavoie, Patrick; Dumont, Katia

2015-11-01

Newly graduated nurses need to demonstrate high levels of competencies when they enter the workplace. A competency-based approach to their education is recommended to ensure patients' needs are met. A continuing education intervention consistent with the competency-based approach to education was designed and implemented in eight care units in two teaching hospitals. It consists of a series of 30-min reflective practice groups on clinical events that newly graduated nurses encountered in their practice. It was evaluated using a descriptive longitudinal evaluative research design, combining individual and group interviews with stakeholders, the analysis of facilitators' journal entries, and a research assistant's field notes. The results suggest that issues associated with the implementation of the continuing education intervention revolved around leadership for managers, flexibility for nursing staff, and role shifting for the facilitators. Newly graduated nurses who participated in the study noted that the reflective practice sessions contributed to the development of both clinical reasoning and leadership. Nursing managers stated the advantages of the intervention on nurses' professional development and for the quality and safety of care. Following the end of the study, participants from two units managed to pursue the activity during their work time. Copyright © 2015 Elsevier Ltd. All rights reserved.

Open for business: a comparative study of websites selling autologous stem cells in Australia and Japan.

PubMed

Munsie, Megan; Lysaght, Tamra; Hendl, Tereza; Tan, Hui-Yin Lynn; Kerridge, Ian; Stewart, Cameron

2017-11-10

This article examines online marketing practices of Japanese and Australian clinics offering putative autologous stem cell treatments. We conducted google searches for keywords related to stem cell therapy and stem cell clinics in English and Japanese. We identified websites promoting 88 point-of-sale clinics in Japan and 70 in Australia. Our findings provide further evidence of the rapid global growth in clinics offering unproven stem cell interventions. We also show that these clinics adopt strategies to promote their services as though they are consistent with evidentiary and ethical standards of science, research and medicine. Unless addressed, these practices risk harming not only vulnerable patients but also undermining public trust in science and medicine.

The discrepancy between patients and informants on clinician-rated measures in major depressive disorder: implications for clinical trials and clinical practice.

PubMed

Peselow, Eric D; Karamians, Reneh; Lord, Marie; Tobia, Gabriel; IsHak, Waguih William

2014-03-01

Clinician-rated measures are used in clinical trials and measurement-based clinical care settings to assess baseline symptoms and treatment outcomes of major depressive disorder (MDD), with a widely held dictum that they are sufficient in assessing the patient's clinical status. In this study, we examined clinician-rated measures of depressive and global symptom severity, obtained by interviewing patients as well as informants in an attempt to examine the potential difference or similarity between these two sources of information. The sample consisted of 89 treatment seeking, DSM-IV diagnosed MDD outpatients treated between 1995 and 2004. The clinician-rated measures used included the Montgomery Åsberg Depression Rating Scale (MADRS), and the Clinical Global Impression Scale (CGI) for Severity. The scores of the clinician-rated measures collected from patients' interviews were compared with those collected from informants' interviews. Clinician-rated scores, collected by interviewing patients, were significantly higher and indicative of greater symptom severity when compared with those collected by interviewing informants. This was true for both the MADRS before (P<0.0001) and after treatment scores (P<0.0001), as well as the CGI before (P<0.0001) and after treatment scores (P<0.0001). Consistently involving informants and the time/burden it takes for them to participate might not be practical in MDD clinical trials or everyday clinical care. The discrepancies observed between the clinician-rated scores obtained from patients and informants emphasize the importance of incorporating collateral information during the assessment and rating of depressive symptom severity in both clinical trials as well as in clinical practice.

The European Clinical Specialization on Fluency Disorders (ECSF)

ERIC Educational Resources Information Center

Eggers, Kurt; Leahy, Margaret

2011-01-01

The European Clinical Specialization on Fluency Disorders (ECSF) project consists of one-year post-qualification fluency specialization training and a harmonized graduate fluency program. It was developed by eight European universities/colleges to provide the means whereby graduates would meet comparable standards of competence to practice in the…

A Practical Approach to Governance and Optimization of Structured Data Elements.

PubMed

Collins, Sarah A; Gesner, Emily; Morgan, Steven; Mar, Perry; Maviglia, Saverio; Colburn, Doreen; Tierney, Diana; Rocha, Roberto

2015-01-01

Definition and configuration of clinical content in an enterprise-wide electronic health record (EHR) implementation is highly complex. Sharing of data definitions across applications within an EHR implementation project may be constrained by practical limitations, including time, tools, and expertise. However, maintaining rigor in an approach to data governance is important for sustainability and consistency. With this understanding, we have defined a practical approach for governance of structured data elements to optimize data definitions given limited resources. This approach includes a 10 step process: 1) identification of clinical topics, 2) creation of draft reference models for clinical topics, 3) scoring of downstream data needs for clinical topics, 4) prioritization of clinical topics, 5) validation of reference models for clinical topics, and 6) calculation of gap analyses of EHR compared against reference model, 7) communication of validated reference models across project members, 8) requested revisions to EHR based on gap analysis, 9) evaluation of usage of reference models across project, and 10) Monitoring for new evidence requiring revisions to reference model.

The Federal Trade Commission, clinical integration, and the organization of physician practice.

PubMed

Casalino, Lawrence P

2006-06-01

This article examines Federal Trade Commission (FTC) policy--in particular, the agency's controversial 1996 statements on clinical integration--toward joint negotiations for nonrisk contracts with health plans by physicians organized into independent practice associations (IPAs) and (with hospitals) into physician-hospital organizations (PHOs). The article concludes that the policy is consistent with anti-trust principles, consistent with current thinking on the use of organized processes to improve medical care quality, specific enough to provide guidance to physicians wanting to integrate clinically, and general enough to encourage ongoing innovations in physician organization. The FTC should consider stronger sanctions for IPAs and PHOs whose clinical integration is nothing more than a sham intended to provide cover for joint negotiations, should give the benefit of the doubt to organizations whose clinical integration appears to be reasonably consonant with the statements, and should clarify several ambiguities in the statements. Health plans should facilitate IPA and PHO efforts to improve care by rewarding quality and efficiency and by providing clinically integrated organizations with claims information on individual patients. Though creating clinically integrated organizations is difficult and expensive, physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patients.

Acute care clinical pharmacy practice: unit- versus service-based models.

PubMed

Haas, Curtis E; Eckel, Stephen; Arif, Sally; Beringer, Paul M; Blake, Elizabeth W; Lardieri, Allison B; Lobo, Bob L; Mercer, Jessica M; Moye, Pamela; Orlando, Patricia L; Wargo, Kurt

2012-02-01

This commentary from the 2010 Task Force on Acute Care Practice Model of the American College of Clinical Pharmacy was developed to compare and contrast the "unit-based" and "service-based" orientation of the clinical pharmacist within an acute care pharmacy practice model and to offer an informed opinion concerning which should be preferred. The clinical pharmacy practice model must facilitate patient-centered care and therefore must position the pharmacist to be an active member of the interprofessional team focused on providing high-quality pharmaceutical care to the patient. Although both models may have advantages and disadvantages, the most important distinction pertains to the patient care role of the clinical pharmacist. The unit-based pharmacist is often in a position of reacting to an established order or decision and frequently is focused on task-oriented clinical services. By definition, the service-based clinical pharmacist functions as a member of the interprofessional team. As a team member, the pharmacist proactively contributes to the decision-making process and the development of patient-centered care plans. The service-based orientation of the pharmacist is consistent with both the practice vision embraced by ACCP and its definition of clinical pharmacy. The task force strongly recommends that institutions pursue a service-based pharmacy practice model to optimally deploy their clinical pharmacists. Those who elect to adopt this recommendation will face challenges in overcoming several resource, technologic, regulatory, and accreditation barriers. However, such challenges must be confronted if clinical pharmacists are to contribute fully to achieving optimal patient outcomes. © 2012 Pharmacotherapy Publications, Inc.

An ethnographic study of nurses' experience with nursing research and its integration in practice.

PubMed

Dupin, Cécile Marie; Borglin, Gunilla; Debout, Christophe; Rothan-Tondeur, Monique

2014-09-01

To report from a study aimed at illuminating how French Registered Nurses experience and engage in nursing research in clinical practice. Nursing research in France is mainly conducted by nurses working at clinical research units rather than by dedicated nurse researchers. Education, i.e. advanced degrees, in the field of nursing research is still in its infancy and not yet consistent with the international context. Outside France, the general perception is that nursing research is a unified part of professional nursing. Consequently, in-depth knowledge about how nurses in a French clinical context might experience and engage in nursing research is still lacking. The design of this study was influenced by an ethnographic approach as described by the French anthropologists Beaud and Weber. Data, participatory observations, field notes and interviews (n = 6) were collected in a teaching hospital between April-August 2012. The field consisted of a wound-care unit and clinical research units. Collected data were analysed based on Beaud and Weber's description of analysis. Three beliefs were identified: being a unified part of a research team, being an integral part of 'crosswise - across' activities and being part of research activities. Commitment to nursing research was strengthened by patient-related issues. Based on this context, nursing research would likely benefit from the support of a naturalized reciprocity between clinical practice and research. © 2014 John Wiley & Sons Ltd.

Clinical practice guidelines and consensus statements in oncology--an assessment of their methodological quality.

PubMed

Jacobs, Carmel; Graham, Ian D; Makarski, Julie; Chassé, Michaël; Fergusson, Dean; Hutton, Brian; Clemons, Mark

2014-01-01

Consensus statements and clinical practice guidelines are widely available for enhancing the care of cancer patients. Despite subtle differences in their definition and purpose, these terms are often used interchangeably. We systematically assessed the methodological quality of consensus statements and clinical practice guidelines published in three commonly read, geographically diverse, cancer-specific journals. Methods Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents. Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents. Thirty-four consensus statements and 67 clinical practice guidelines were evaluated. The rigour of development score for consensus statements over the three journals was 32% lower than that of clinical practice guidelines. The editorial independence score was 15% lower for consensus statements than clinical practice guidelines. One journal scored consistently lower than the others over both domains. No journals adhered to all the items related to the transparency of document development. One journal's consensus statements endorsed a product made by the sponsoring pharmaceutical company in 64% of cases. Guidance documents are an essential part of oncology care and should be subjected to a rigorous and validated development process. Consensus statements had lower methodological quality than clinical practice guidelines using AGREE II. At a minimum, journals should ensure that that all consensus statements and clinical practice guidelines adhere to AGREE II criteria. Journals should consider explicitly requiring guidelines to declare pharmaceutical company sponsorship and to identify the sponsor's product to enhance transparency.

Psychometric Properties of the Breast Cancer Screening Beliefs Questionnaire Among Women of Indian Ethnicity Living in Australia.

PubMed

Kwok, Cannas; Pillay, Rona; Lee, Chun Fan

2016-01-01

Indian women have been consistently reported as having low participation in breast cancer screening practices. A valid and reliable instrument to explore their breast cancer beliefs is essential for development of interventions to promote breast cancer screening practices. The aim of this study was to report the psychometric properties of the Breast Cancer Screening Beliefs Questionnaire (BCSBQ) in an Indian community in Australia. A convenience sample of 242 Indian Australian women was recruited from Indian community organizations and personal networking. Explanatory factor analysis was conducted to study the factor structure. Clinical validity was examined by Cuzick's nonparametric test, and Cronbach's α was used to assess internal consistency reliability. Exploratory factor analysis showed a similar fit to the hypothesized 3-factor structure. The frequency of breast cancer screening practices was significantly associated with attitudes toward general health check-up. Knowledge and perceptions about the breast cancer scale were not significantly associated with clinical breast examinations and mammography. Perceived barriers to mammography were much less evident among women who engaged in breast awareness and clinical breast examination. Results indicated that the BCSBQ had satisfactory validity and internal consistency. Cronbach's α of the 3 subscales ranged from .81 to .91. The BCSBQ is a culturally appropriate, valid, and reliable instrument for assessing the beliefs, knowledge, and attitudes about breast cancer and breast cancer screening practices among women of Indian ethnic extraction living in Australia. The BCSBQ can be used to provide nurses with information relevant for the development of culturally sensitive breast health education programs.

Mental Workload as a Key Factor in Clinical Decision Making

ERIC Educational Resources Information Center

Byrne, Aidan

2013-01-01

The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive…

A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study

PubMed Central

Slater, Helen; Davies, Stephanie Joy; Parsons, Richard; Quintner, John Louis; Schug, Stephan Alexander

2012-01-01

Background Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs). Methods To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 =  nil and 5 =  excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale). Results Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change  = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention. Conclusion An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice. PMID:22662264

MO-D-211-01: Medical Physics Practice Guidelines - The Minimum Level of Medical Physics Support in Clinical Practice Settings.

PubMed

Chan, M; Fontenot, J; Halvorsen, P

2012-06-01

The American Association of Physicists in Medicine (AAPM) has long advocated a consistent level of medical physics practice, and has published many guidelines and position statements toward that goal, such as Science Council Task Group reports related to calibration and quality assurance, Education Council and Professional Council Task Group reports related to education, training, and peer review, and Board-approved Position Statements related to the Scope of Practice, physicist qualifications, and other aspects of medical physicspractice. Despite these concerted and enduring efforts, the profession does not have a clear and concise statement of the acceptable practice guidelines for routine clinical medical physics. As accreditation of clinical practices becomes more common, Medical Physics Practice Guidelines (MPPGs) will be crucial to ensuring a consistent benchmark for accreditation programs. The AAPM will lead the development of MPPGs in collaboration with other professional societies. The MPPGs will be freely available to the general public. Accrediting organizations, regulatory agencies and legislators will be encouraged to reference these MPPGs when defining their respective requirements. MPPGs are intended to provide the medical community with a clear description of the minimum level of medical physics support that the AAPM would consider to be prudent in all clinical practice settings. Support includes but is not limited to staffing, equipment, machine access, and training. These MPPGs are not designed to replace extensive Task Group reports or review articles, but rather to describe the recommended minimum level of medical physics support for specific clinical services. This course will describe the purpose and scope of MPPGs, the procedure for the development of a MPPG, as well as the progress of Therapy MPPG TG #1 on "Evaluation and quality assurance of x-ray based image guided radiotherapy systems" and Diagnostic MPPG TG #2 on "CT Protocol management and review". 1. Understand the concept and scope of MPPG from the AAPM 2. Understand the benefits and process of the development of MPPG by the AAPM 3. Understand the goals and methodology of the Therapy MPPG Task Group #14. 4. Understand the strategic plans from Professional Council towards the AAPM initiatives. © 2012 American Association of Physicists in Medicine.

A policy-into-practice intervention to increase the uptake of evidence-based management of low back pain in primary care: a prospective cohort study.

PubMed

Slater, Helen; Davies, Stephanie Joy; Parsons, Richard; Quintner, John Louis; Schug, Stephan Alexander

2012-01-01

Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs). To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1  =  nil and 5  =  excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale). Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change  =  -5.6±8.2, p<0.0001; 95% confidence interval: -7.6 to -3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention. An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.

Learning experiences and assessment in the first 2 years of the medical course at King's College London School of Medicine.

PubMed

Papachristodoulou, Despo

2010-01-01

The medical curriculum at King's College London School of Medicine is a 5 year course; an extended program (6 years) and a graduate entry program (4 years) are also available. The first 2 years of the curriculum comprise phases 1 and 2. The curriculum consists of core material that is common to all students and student-selected components (students undertake three such components in the first 2 years). Phase 1 lasts 12 weeks and students learn the principles of tissue and organ structure and function. They are also introduced to the practice of medicine (concepts of health, communication, ethics, inter-professional education and medicine in the community). Phase 2 consists of 36 weekly clinical scenarios that place basic medical science in a clinical context. Phase 2 covers cardiovascular, respiratory, gastrointestinal, renal and musculoskeletal systems; nutrition; endocrinology; head and neck anatomy; neuroscience; genetics; and infections. Teaching continues in pri! mary care and in the hospitals and includes basic and advanced life support. Learning experiences include lectures, tutorials, practical classes, dissection and prosection, communication skills, e-learning, student-led sessions and primary care and hospital visits. Assessment consists of in-course assessment (e.g., presentations, tests and essays) and end-of-year examinations which consist of written papers and an objective structured clinical examination at the end of year 2. The main strengths of the program include the scenario format of learning and the practice of medicine early on. The difficulties arise mainly from the large numbers of students (420 per year).

Quality assurance of the clinical learning environment in Austria: Construct validity of the Clinical Learning Environment, Supervision and Nurse Teacher Scale (CLES+T scale).

PubMed

Mueller, Gerhard; Mylonas, Demetrius; Schumacher, Petra

2018-07-01

Within nursing education, the clinical learning environment is of a high importance in regards to the development of competencies and abilities. The organization, atmosphere, and supervision in the clinical learning environment are only a few factors that influence this development. In Austria there is currently no valid instrument available for the evaluation of influencing factors. The aim of the study was to test the construct validity with principal component analysis as well as the internal consistency of the German Clinical Learning Environment, Supervision and Teacher Scale (CLES+T scale) in Austria. The present validation study has a descriptive-quantitative cross-sectional design. The sample consisted of 385 nursing students from thirteen training institutions in Austria. The data collection was carried out online between March and April 2016. Starting with a polychoric correlation matrix, a parallel analysis with principal component extraction and promax rotation was carried out due to the ordinal data. The exploratory ordinal factor analysis supported a four-component solution and explained 73% of the total variance. The internal consistency of all 25 items reached a Cronbach's α of 0.95 and the four components ranged between 0.83 and 0.95. The German version of the CLES+T scale seems to be a useful instrument for identifying potential areas of improvement in clinical practice in order to derive specific quality measures for the practical learning environment. Copyright © 2018 Elsevier Ltd. All rights reserved.

Replication of clinical innovations in multiple medical practices.

PubMed

Henley, N S; Pearce, J; Phillips, L A; Weir, S

1998-11-01

Many clinical innovations had been successfully developed and piloted in individual medical practice units of Kaiser Permanente in North Carolina during 1995 and 1996. Difficulty in replicating these clinical innovations consistently throughout all 21 medical practice units led to development of the interdisciplinary Clinical Innovation Implementation Team, which was formed by using existing resources from various departments across the region. REPLICATION MODEL: Based on a model of transfer of best practices, the implementation team developed a process and tools (master schedule and activity matrix) to quickly replicate successful pilot projects throughout all medical practice units. The process involved the following steps: identifying a practice and delineating its characteristics and measures (source identification); identifying a team to receive the (new) practice; piloting the practice; and standardizing, including the incorporation of learnings. The model includes the following components for each innovation: sending and receiving teams, an innovation coordinator role, an innovation expert role, a location expert role, a master schedule, and a project activity matrix. Communication depended on a partnership among the location experts (local knowledge and credibility), the innovation coordinator (process expertise), and the innovation experts (content expertise). Results after 12 months of working with the 21 medical practice units include integration of diabetes care team services into the practices, training of more than 120 providers in the use of personal computers and an icon-based clinical information system, and integration of a planwide self-care program into the medical practices--all with measurable improved outcomes. The model for sequential replication and the implementation team structure and function should be successful in other organizational settings.

Salivary diagnostics and its impact in dentistry, research, education, and the professional community.

PubMed

Slavkin, H C; Fox, C H; Meyer, D M

2011-10-01

Oral fluid-based (salivary) tests have the potential to create practical, point-of-care clinical instruments that are convenient, practical, and comfortable to use in dentistry and medicine. Currently, there are no simple, accurate, and inexpensive sampling, screening, or detection methods to support definitive diagnostic platforms across dental and medical disciplines. Though the benefits from advancing screening and detection technologies seem eminent, analytical, chemical, molecular, genetic, and protein markers are still under development. Clinical applications in patient care must be validated independently to ensure that they are clinically accurate, reliable, precise, and uniformly consistent for screening and detecting specific diseases or conditions. As technology designed to improve patient care through risk assessment, prevention, and disease management is transferred into clinical practice, dentistry may need to reassess its role in general health care. © International & American Associations for Dental Research

Studying physician-adolescent patient communication in community-based practices: recruitment challenges and solutions.

PubMed

Bodner, Michael E; Bilheimer, Alicia; Gao, Xiaomei; Lyna, Pauline; Alexander, Stewart C; Dolor, Rowena J; Østbye, Truls; Bravender, Terrill; Tulsky, James A; Graves, Sidney; Irons, Alexis; Pollak, Kathryn I

2015-11-13

Practice-based studies are needed to assess how physicians communicate health messages about weight to overweight/obese adolescent patients, but successful recruitment to such studies is challenging. This paper describes challenges, solutions, and lessons learned to recruit physicians and adolescents to the Teen Communicating Health Analyzing Talk (CHAT) study, a randomized controlled trial of a communication skills intervention for primary care physicians to enhance communication about weight with overweight/obese adolescents. A "peer-to-peer" approach was used to recruit physicians, including the use of "clinic champions" who liaised between study leaders and physicians. Consistent rapport and cooperative working relationships with physicians and clinic staff were developed and maintained. Adolescent clinic files were reviewed (HIPAA waiver) to assess eligibility. Parents could elect to opt-out for their children. To encourage enrollment, confidentiality of audio recordings was emphasized, and financial incentives were offered to all participants. We recruited 49 physicians and audio-recorded 391 of their overweight/obese adolescents' visits. Recruitment challenges included 1) physician reticence to participate; 2) variability in clinic operating procedures; 3) variability in adolescent accrual rates; 4) clinic open access scheduling; and 5) establishing communication with parents and adolescents. Key solutions included the use of a "clinic champion" to help recruit physicians, pro-active, consistent communication with clinic staff, and adapting calling times to reach parents and adolescents. Recruiting physicians and adolescents to audio-recorded, practice-based health communication studies can be successful. Anticipated challenges to recruiting can be met with advanced planning; however, optimal solutions to challenges evolve as recruitment progresses.

Geriatric simulation: practicing management and leadership in care of the older adult.

PubMed

Miller, Sally; Overstreet, Maria

2015-06-01

According to the Centers for Disease Control and Prevention, patients age 65 and older account for 43% of hospital days. The complexity of caring for older adults affords nursing students opportunities to assess, prioritize, intervene, advocate, and experience being a member of an interdisciplinary health care team. However, these multifaceted hospital experiences are not consistently available for all students. Nursing clinical simulation (NCS) can augment or replace specific clinical hours and provide clinically relevant experiences to practice management and leadership skills while caring for older adults. This article describes a geriatric management and leadership NCS. Copyright © 2015 Elsevier Inc. All rights reserved.

Yoga and immune system functioning: a systematic review of randomized controlled trials.

PubMed

Falkenberg, R I; Eising, C; Peters, M L

2018-02-10

Yoga is an ancient mind-body practice that is increasingly recognized to have health benefits in a variety of clinical and non-clinical conditions. This systematic review summarizes the findings of randomized controlled trials examining the effects of yoga on immune system functioning which is imperative to justify its application in the clinic. Fifteen RCTs were eligible for the review. Even though the existing evidence is not entirely consistent, a general pattern emerged suggesting that yoga can downregulate pro-inflammatory markers. In particular, the qualitative evaluation of RCTs revealed decreases in IL-1beta, as well as indications for reductions in IL-6 and TNF-alpha. These results imply that yoga may be implemented as a complementary intervention for populations at risk or already suffering from diseases with an inflammatory component. Beyond this, yoga practice may exert further beneficial effects by enhancing cell-mediated and mucosal immunity. It is hypothesized that longer time spans of yoga practice are required to achieve consistent effects especially on circulating inflammatory markers. Overall, this field of investigation is still young, hence the current body of evidence is small and for most immune parameters, more research is required to draw distinct conclusions.

Factors related to nursing students' readiness to enter working life - A scoping literature review.

PubMed

Järvinen, Tiina; Eklöf, Niina; Salminen, Leena

2018-03-01

The aim of this scoping literature review was to identify the factors related to nursing students' readiness to enter working life. The literature search was carried out in autumn 2017 in PubMed and CINAHL databases. The studies selected for this review (n = 17) were analyzed thematically with inductive content analysis. Four subthemes that were combined into two main factors related to nursing students' readiness to enter working life were found. The main factors found were 1) educational factors and 2) personal factors. Educational factors consisted of professional competence and clinical practice, while personal factors consisted of nursing students' background and feelings. Some nursing students tend to feel insecure about entering working life as a newly graduated nurse. This literature review also supports the importance of clinical practice periods in nursing education and for readiness for working life. Nurse education needs to ensure clinical practice periods which support nursing students' professional growth. Further research is needed on how the factors related to nursing students' readiness to enter working life correlate with each other. Particularly, the association between competence, readiness and positive feelings towards graduation needs further investigation. Copyright © 2018 Elsevier Ltd. All rights reserved.

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework.

PubMed

Kontopantelis, Evangelos; Buchan, Iain; Reeves, David; Checkland, Kath; Doran, Tim

2013-08-02

To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system. Retrospective longitudinal study. Data for 2007-2008 to 2010-2011, extracted from the clinical computer systems of general practices in England. All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice. Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement. Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels). Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system.

A mixed methods approach to adapting health-related quality of life measures for use in routine oncology clinical practice.

PubMed

Harley, Clare; Takeuchi, Elena; Taylor, Sally; Keding, Ada; Absolom, Kate; Brown, Julia; Velikova, Galina

2012-04-01

The current study reviewed and adapted existing health-related quality of life (HRQoL) instruments for use in routine clinical practice delivering outpatient chemotherapy for colorectal, breast and gynaecological cancers. 564 (288 gynaecological, 208 breast and 68 colorectal) outpatient consultations of 141 patients were audio-recorded and analysed to identify discussed issues. Issues were ranked from most to least commonly discussed within each disease group. Existing HRQoL instruments were evaluated against these lists and best fitting items entered into cancer-specific item banks. Item banks were evaluated during semi-structured interviews by twenty-one oncologists (13 consultants and 8 specialist registrars), four clinical nurse specialists and thirty patients, from breast, gynaecological and colorectal cancer practices. Pilot questionnaires were completed by 448 (145 breast, 148 gynaecological and 155 colorectal) patients attending outpatient clinics. Item selection and scale reliability was explored using descriptive data and psychometric methods alongside qualitative patient and clinician ratings. Each questionnaire includes five physical and three psychosocial function scales each with good internal consistency reliability (α > 0.70) plus disease-specific individual-symptom items identified as useful in clinical practice. Three cancer-specific health-related quality of life measures were developed for use in routine clinical practice. Initial analyses suggest good clinical utility and acceptable psychometric properties for the new instruments.

Broadening Perspectives on Clinical Performance Assessment: Rethinking the Nature of In-Training Assessment

ERIC Educational Resources Information Center

Govaerts, Marjan J. B.; van der Vleuten, Cees P. M.; Schuwirth, Lambert W. T.; Muijtjens, Arno M. M.

2007-01-01

Context: In-training assessment (ITA), defined as multiple assessments of performance in the setting of day-to-day practice, is an invaluable tool in assessment programmes which aim to assess professional competence in a comprehensive and valid way. Research on clinical performance ratings, however, consistently shows weaknesses concerning…

A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set.

PubMed

Mor, Vincent

2004-04-01

The Minimum Data Set (MDS) for nursing home (NH) resident assessment, designed to assess elders functional status and care needs, exemplifies how the information needs of clinical practice are congruent with those of research. Building on a review of the published literature, this article describes the development of the MDS, its reliability and validity testing, as well as the variety of different policy and research uses to which it has been applied. Interrater reliability of items and internal consistency of MDS summary scales is generally good to excellent. Validation studies reveal good correspondence to research quality instruments for cognition, activities of daily living, and diagnoses with more variable results for vision, pain, mood, and behavior scales. To date, no consistent evidence suggests that applications of MDS data for case-mix reimbursement and quality indicator monitoring systematically bias the data. Although facility variation in data quality could compromise some applications, creation of the MDS as a clinical tool for care planning provides an example of how assessment tools with clinical use can be used in administrative databases for research and policy applications.

Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study

PubMed Central

2011-01-01

Background Type 2 diabetes is an increasingly prevalent chronic illness and an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of primary care teams. This study aimed to: investigate theoretically-based organisational, team, and individual factors determining the multiple behaviours needed to manage diabetes; and identify multilevel determinants of different diabetes management behaviours and potential interventions to improve them. This paper describes the instrument development, study recruitment, characteristics of the study participating practices and their constituent healthcare professionals and administrative staff and reports descriptive analyses of the data collected. Methods The study was a predictive study over a 12-month period. Practices (N = 99) were recruited from within the UK Medical Research Council General Practice Research Framework. We identified six behaviours chosen to cover a range of clinical activities (prescribing, non-prescribing), reflect decisions that were not necessarily straightforward (controlling blood pressure that was above target despite other drug treatment), and reflect recommended best practice as described by national guidelines. Practice attributes and a wide range of individually reported measures were assessed at baseline; measures of clinical outcome were collected over the ensuing 12 months, and a number of proxy measures of behaviour were collected at baseline and at 12 months. Data were collected by telephone interview, postal questionnaire (organisational and clinical) to practice staff, postal questionnaire to patients, and by computer data extraction query. Results All 99 practices completed a telephone interview and responded to baseline questionnaires. The organisational questionnaire was completed by 931/1236 (75.3%) administrative staff, 423/529 (80.0%) primary care doctors, and 255/314 (81.2%) nurses. Clinical questionnaires were completed by 326/361 (90.3%) primary care doctors and 163/186 (87.6%) nurses. At a practice level, we achieved response rates of 100% from clinicians in 40 practices and > 80% from clinicians in 67 practices. All measures had satisfactory internal consistency (alpha coefficient range from 0.61 to 0.97; Pearson correlation coefficient (two item measures) 0.32 to 0.81); scores were generally consistent with good practice. Measures of behaviour showed relatively high rates of performance of the six behaviours, but with considerable variability within and across the behaviours and measures. Discussion We have assembled an unparalleled data set from clinicians reporting on their cognitions in relation to the performance of six clinical behaviours involved in the management of people with one chronic disease (diabetes mellitus), using a range of organisational and individual level measures as well as information on the structure of the practice teams and across a large number of UK primary care practices. We would welcome approaches from other researchers to collaborate on the analysis of this data. PMID:21658211

Current practices for evaluation of resonance disorders in North America.

PubMed

Stelck, Elizabeth Huebert; Boliek, Carol A; Hagler, Paul H; Rieger, Jana M

2011-02-01

Improving treatment outcomes for people with resonance problems (due to velopharyngeal disorders) is a priority for many speech-language pathologists (SLPs), but there exists a limited understanding of the practices SLPs are using to assess and monitor therapeutic effects in this population. The current study was designed to answer the following questions: (1) What are current clinical practices versus best practices for assessing resonance disorders, tracking therapeutic effects, and determining discharge criteria? (2) What assessment practices would SLPs prefer to use with clients who have resonance disorders? (3) What are barriers to SLPs' use of best practices? and (4) What effects do SLP demographics have on clinical practices? Thirty-eight SLPs, specializing in the treatment of resonance disorders, participated in the study. Responses were compared with best practice recommendations derived from the literature. Most clinicians were using low-tech assessment tools, often because they lacked access to high-tech tools. Demographics and training did not affect clinical assessment practices. There is a need to increase the availability of high-tech assessment tools to SLPs practicing in the area of resonance disorders, as consistent use of sophisticated assessment devices would exemplify contemporary thinking about the transfer of knowledge to practice in this area. © Thieme Medical Publishers.

Evidence-based clinical practice guidelines for chronic pancreatitis 2015.

PubMed

Ito, Tetsuhide; Ishiguro, Hiroshi; Ohara, Hirotaka; Kamisawa, Terumi; Sakagami, Junichi; Sata, Naohiro; Takeyama, Yoshifumi; Hirota, Morihisa; Miyakawa, Hiroyuki; Igarashi, Hisato; Lee, Lingaku; Fujiyama, Takashi; Hijioka, Masayuki; Ueda, Keijiro; Tachibana, Yuichi; Sogame, Yoshio; Yasuda, Hiroaki; Kato, Ryusuke; Kataoka, Keisho; Shiratori, Keiko; Sugiyama, Masanori; Okazaki, Kazuichi; Kawa, Shigeyuki; Tando, Yusuke; Kinoshita, Yoshikazu; Watanabe, Mamoru; Shimosegawa, Tooru

2016-02-01

Chronic pancreatitis is considered to be an irreversible progressive chronic inflammatory disease. The etiology and pathology of chronic pancreatitis are complex; therefore, it is important to correctly understand the stage and pathology and provide appropriate treatment accordingly. The newly revised Clinical Practice Guidelines of Chronic Pancreatitis 2015 consist of four chapters, i.e., diagnosis, staging, treatment, and prognosis, and includes a total of 65 clinical questions. These guidelines have aimed at providing certain directions and clinically practical contents for the management of chronic pancreatitis, preferentially adopting clinically useful articles. These revised guidelines also refer to early chronic pancreatitis based on the Criteria for the Diagnosis of Chronic Pancreatitis 2009. They include such items as health insurance coverage of high-titer lipase preparations and extracorporeal shock wave lithotripsy, new antidiabetic drugs, and the definition of and treatment approach to pancreatic pseudocyst. The accuracy of these guidelines has been improved by examining and adopting new evidence obtained after the publication of the first edition.

Biothermal Model of Patient for Brain Hypothermia Treatment

NASA Astrophysics Data System (ADS)

Wakamatsu, Hidetoshi; Gaohua, Lu

A biothermal model of patient is proposed and verified for the brain hypothermia treatment, since the conventionally applied biothermal models are inappropriate for their unprecedented application. The model is constructed on the basis of the clinical practice of the pertinent therapy and characterized by the mathematical relation with variable ambient temperatures, in consideration of the clinical treatments such as the vital cardiopulmonary regulation. It has geometrically clear representation of multi-segmental core-shell structure, database of physiological and physical parameters with a systemic state equation setting the initial temperature of each compartment. Its step response gives the time constant about 3 hours in agreement with clinical knowledge. As for the essential property of the model, the dynamic temperature of its face-core compartment is realized, which corresponds to the tympanic membrane temperature measured under the practical anesthesia. From the various simulations consistent with the phenomena of clinical practice, it is concluded that the proposed model is appropriate for the theoretical analysis and clinical application to the brain hypothermia treatment.

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice.

PubMed

Jacobi, Judith; Ray, Shaunta'; Danelich, Ilya; Dodds Ashley, Elizabeth; Eckel, Stephen; Guharoy, Roy; Militello, Michael; O'Donnell, Paul; Sam, Teena; Crist, Stephanie M; Smidt, Danielle

2016-05-01

This paper describes the goals of the American Society of Health-System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health-system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication-related outcomes and technicians assume greater responsibility for product-related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed. © 2016 Pharmacotherapy Publications, Inc.

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia.

PubMed

Owen, Richard R; Fischer, Ellen P; Kirchner, JoAnn E; Thrush, Carol R; Williams, D Keith; Cuffel, Brian J; Elliott, Carl E; Booth, Brenda M

2003-01-01

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.

A cost-effective method to characterize variation in clinical practice.

PubMed

Chang, K; Sauereisen, S; Dlutowski, M; Veloski, J J; Nash, D B

1999-06-01

This study's objective was to measure variation in physicians' practice styles and policies. Family physicians and general internists were surveyed about evidence-based medicine in the areas of asthma, congestive heart failure, and diabetes mellitus. They were asked about clinical recommendations where standards of practice were uncertain, controversial, or changing in response to published guidelines. Also included were items dealing with managed care. Although there was wide variation in responses to 20 of 36 items, some responses were consistent with practice guidelines. Responses to several items indicated a tendency to overuse expensive tests. Overall, the results indicate that a brief, open-ended survey can assess practice variation quickly and economically, as contrasted with more expensive analyses of medical records or claims data. With proper validation such assessments can be used as baselines to guide interventions, as well as measures of the outcomes of these interventions to change practice styles.

The Vanderbilt Professional Nursing Practice Program, part 3: managing an advancement process.

PubMed

Steaban, Robin; Fudge, Mitzie; Leutgens, Wendy; Wells, Nancy

2003-11-01

Consistency of performance standards across multiple clinical settings is an essential component of a credible advancement system. Our advancement process incorporates a central committee, composed of nurses from all clinical settings within the institution, to ensure consistency of performance in inpatient, outpatient, and procedural settings. An analysis of nurses advanced during the first 18 months of the program indicates that performance standards are applicable to nurses in all clinical settings. The first article (September 2003) in this 3-part series described the foundation for and the philosophical background of the Vanderbilt Professional Nursing Practice Program (VPNPP), the career advancement program underway at Vanderbilt University Medical Center. Part 2 described the development of the evaluation tools used in the VPNPP, the implementation and management of this new system, program evaluation, and improvements since the program's inception. The purpose of this article is to review the advancement process, review the roles of those involved in the process, and to describe outcomes and lessons learned.

A National Survey of the Nursing Care of Infants With Prenatal Substance Exposure in Canadian NICUs.

PubMed

Marcellus, Lenora; Loutit, Tara; Cross, Shannon

2015-10-01

Many communities are reporting increases in the number of infants requiring NICU care. Practices continue to vary and there is limited available evidence about nursing care. The purpose of this study was to describe current nursing care practices for infants with prenatal substance exposure in the NICU setting and during transition to the community. Findings from this study were compared with an earlier Canadian survey (by Marcellus in 2002) to identify shifts in clinical nursing practice for this population. This was a cross-sectional descriptive survey design. A 68-item survey composed of multiple-choice and open-ended questions was administered through FluidSurveys online software. A convenience sample of 62 clinical managers or clinical educators in hospitals with active maternal-infant clinical units with 500 deliveries or more annually and/or pediatric hospitals with a separate designated neonatal service (ie, Level 2 and 3 units) was chosen. A greater number of NICUs are using clinical guidelines to support the standardization of quality care. Improvements in nursing practice were identified and these included the consistent use of a withdrawal scoring tool and provision of education for team members in orientation. A decline in routine discharge planning meetings and routine parent teaching plans was discovered. This survey has improved understanding of the current state of nursing care for infants with prenatal substance exposure and their families during this critical time of transition. The purpose of the survey was to compare findings with the 2002 study by Marcellus to identify any improved practices and describe current state nursing care practices in the NICU. Practice changes over the last decade have included keeping mothers and infants together, expanding concepts of the team, integrating programs and services across hospital and community settings, and creating opportunities for NICU teams to learn more about substance use, mental health, violence, and trauma. Focus on discharge planning, parent teaching, and creation and implementation of national/hospital guidelines is essential for consistent evidence-based quality patient care.

[Development of clinical trial education program for pharmaceutical science students through small group discussion and role-playing using protocol].

PubMed

Imakyure, Osamu; Shuto, Hideki; Nishikawa, Fumi; Hagiwara, Yoshifuka; Inoue, Sachiko; Koyanagi, Taeko; Hirakawa, Masaaki; Kataoka, Yasufumi

2010-08-01

The acquirement of basic knowledge of clinical trials and professional attitude in their practices is a general instructional objective in the Model Core Curriculum for Pharmaceutical Education. Unfortunately, the previous program of clinical trial education was not effective in the acquirement of a professional attitude in their practices. Then, we developed the new clinical trial education program using protocol through small group discussion (SGD) and roll-playing. Our program consists of 7 steps of practical training. In step 1, the students find some problems after presentation of the protocol including case and prescription. In step 2, they analyse the extracted problems and share the information obtained in SGD. In steps 3 and 5, five clinical case scenarios are presented to the students and they discuss which case is suitable for entry to the clinical trial or which case corresponds to the discontinuance criteria in the present designed protocol. In steps 4 and 6, the roll-playing is performed by teachers and students as doctors and clinical research coordinators (CRC) respectively. Further, we conducted a trial practice based on this program for the students. In the student's self-evaluation into five grades, the average score of the skill acquisition level in each step was 3.8-4.7 grade. Our clinical trial education program could be effective in educating the candidates for CRC or clinical pharmacists.

Cost analysis of laparoscopic gastric bypass practice using current Medicare reimbursement and practice costs.

PubMed

Madan, Atul K; Powelson, Jill E; Tichansky, David S

2008-01-01

We performed a formal cost analysis of a hypothetical bariatric practice consisting of a surgeon, dietitian, clinical coordinator/office manager, receptionist, and certified medical assistant to determine whether a bariatric practice would have a difficult time surviving financially with the current Medicare reimbursement. The number of possible cases was calculated for the 2005 calendar year. Most of the costs and assumptions were taken from an actual bariatric practice. The malpractice insurance premium (but not physician salary and benefits) was calculated into the practice cost. With a total of 231 days available for clinical work in 2005, 300 scheduled laparoscopic gastric bypasses could have been performed to allow for appropriate clinic time for new patient visits, postoperative visits, and annual visits. The total reimbursement from Medicare would have been $516,158, with most of the reimbursement coming from procedure fees ($407,063). The total practice cost would have been $444,592. Most of the costs were clinic staff salary and benefits ($207,065) and the malpractice premium ($55,150). The net difference of $71,566 was left to pay the salary and benefits of the bariatric surgeon. The low reimbursement of Medicare for laparoscopic gastric bypass threatens the financial viability of a bariatric surgery practice. With the increasing cost of malpractice and the threatened decrease in Medicare physician reimbursement, Medicare recipients could see a decrease in the number of bariatric surgeons offering them service.

Actual vs perceived performance debriefing in surgery: practice far from perfect.

PubMed

Ahmed, Maria; Sevdalis, Nick; Vincent, Charles; Arora, Sonal

2013-04-01

Performance feedback or debriefing in surgery is increasingly recognized as an essential means to optimize learning in the operating room (OR). However, there is a lack of evidence regarding the current practice and barriers to debriefing in the OR. Phase 1 consisted of semistructured interviews with surgical trainers and trainees to identify features of an effective debriefing and perceived barriers to debriefing. Phase 2 consisted of ethnographic observations of surgical cases to identify current practice and observed barriers to debriefing. Surgical trainers and trainees identified key features of effective debriefing with regard to the approach and content; however, these were not commonly identified in practice. Culture was recognized as a significant barrier to debriefing across both phases of the study. There is a disparity between what the surgical community views as effective debriefing and actual debriefing practices in the OR. Improvements to the current debriefing culture and practice within the field of surgery should be considered to facilitate learning from clinical practice. Copyright © 2013. Published by Elsevier Inc.

Implementing clinical process management of vascular wounds in a tertiary facility: impact evaluation of a performance improvement project.

PubMed

Avruscio, Giampiero; Tocco-Tussardi, Ilaria; Bordignon, Greta; Vindigni, Vincenzo

2017-01-01

Chronic vascular wounds have a significant economic and social impact on our society calling for allocation of a great deal of attention and resources. Efforts should be oriented toward the achievement of the most effective and efficient clinical management. The Angiology Unit at the University Hospital of Padova, Italy, developed a performance improvement project to enhance the quality of practice for vascular ulcers. The project consisted in a multistep process comprising a critical revision of the previous clinical process management, staff education, tightening connections between operators and services, and creation of a position for a wound care nurse. The previous standard of practice was modified according to the results of revision and the current evidence-based practice. The new standard of practice reached its full application in September 2015. The number of patients treated and the number of visits in 2015 remained almost unvaried from 2014. However, the total annual expenditure for treating vascular ulcers was reduced by ~60% from the previous year. Standardization of guidelines and practice is effective in creating an efficient clinical management and in reducing the economic burden of vascular ulcers.

Tensions in learning professional identities - nursing students' narratives and participation in practical skills during their clinical practice: an ethnographic study.

PubMed

Ewertsson, Mona; Bagga-Gupta, Sangeeta; Allvin, Renée; Blomberg, Karin

2017-01-01

Clinical practice is a pivotal part of nursing education. It provides students with the opportunity to put the knowledge and skills they have acquired from lectures into practice with real patients, under the guidance of registered nurses. Clinical experience is also essential for shaping the nursing students' identity as future professional nurses. There is a lack of knowledge and understanding of the ways in which students learn practical skills and apply knowledge within and across different contexts, i.e. how they apply clinical skills, learnt in the laboratory in university settings, in the clinical setting. The aim of this study was therefore to explore how nursing students describe, and use, their prior experiences related to practical skills during their clinical practice. An ethnographic case study design was used. Fieldwork included participant observations (82 h), informal conversations, and interviews ( n  = 7) that were conducted during nursing students' ( n  = 17) clinical practice at an emergency department at a university hospital in Sweden. The overarching theme identified was "Learning about professional identities with respect to situated power". This encompasses tensions in students' learning when they are socialized into practical skills in the nursing profession. This overarching theme consists of three sub-themes: "Embodied knowledge", "Divergent ways of assessing and evaluating knowledge" and "Balancing approaches". Nursing students do not automatically possess the ability to transfer knowledge from one setting to another; rather, their development is shaped by their experiences and interactions with others when they meet real patients. The study revealed different ways in which students navigated tensions related to power differentials. Reflecting on actions is a prerequisite for developing and learning practical skills and professional identities. This highlights the importance of both educators' and the preceptors' roles for socializing students in this process.

Determining the opinions of the first-year nursing students about clinical practice and clinical educators.

PubMed

Kol, Emine; İnce, Serpil

2018-05-01

The clinical experience prepares nursing students to become competent and professional practitioners. The evaluation of the clinical learning environment is important to determine if the clinical experience and clinical instructor provide essential learning opportunities as well as a supportive environment. This study aimed to determine the opinions of first-year nursing students about their instructors and clinical practice in the clinical education setting. The sample of the study consists of 227 students from Akdeniz University Nursing Faculty enrolled in the 'Nursing Basics' course. The mean age of the students was 19.30 ± 0.83, and 74% of the students stated that they were satisfied with clinical practice. During clinical applications, 70.8% of the students were guided by one nurse and one educator while 20.4% and 8.8% were accompanied with only an educator and only a nurse, respectively. A review of the opinions of the students about their educators revealed that they held positive opinions about the educators in terms of adequate theoretical knowledge (74.1%), openness to dialogue (67.9%), encouraging students to do research (62.7%), giving support to students during clinical practice (61.6%), and appreciating the positive behaviours of students (61.7%). In conclusion, it was determined that, although the students regarded the educators as competent in terms of theoretical knowledge and skill and successful in motivating, orienting, and encouraging the students, they viewed inaccessibility of educators as the leading problem. Copyright © 2018. Published by Elsevier Ltd.

Factors influencing the perceived quality of clinical supervision of occupational therapists in a large Australian state.

PubMed

Martin, Priya; Kumar, Saravana; Lizarondo, Lucylynn; Tyack, Zephanie

2016-10-01

Clinical supervision is important for effective health service delivery, professional development and practice. Despite its importance there is a lack of evidence regarding the factors that improve its quality. This study aimed to investigate the factors that influence the quality of clinical supervision of occupational therapists employed in a large public sector health service covering mental health, paediatrics, adult physical and other practice areas. A mixed method, sequential explanatory study design was used consisting of two phases. This article reports the quantitative phase (Phase One) which involved administration of the Manchester Clinical Supervision Scale (MCSS-26) to 207 occupational therapists. Frequency of supervision sessions, choice of supervisor and the type of supervision were found to be the predictor variables with a positive and significant influence on the quality of clinical supervision. Factors such as age, length of supervision and the area of practice were found to be the predictor variables with a negative and significant influence on the quality of clinical supervision. Factors that influence the perceived quality of clinical supervision among occupational therapists have been identified. High quality clinical supervision is an important component of clinical governance and has been shown to be beneficial to practitioners, patients and the organisation. Information on factors that make clinical supervision effective identified in this study can be added to existing supervision training and practices to improve the quality of clinical supervision. © 2016 Occupational Therapy Australia.

Integrating Technologies, Methodologies, and Databases into a Comprehensive Terminology Management Environment to Support Interoperability among Clinical Information Systems

ERIC Educational Resources Information Center

Shakib, Shaun Cameron

2013-01-01

Controlled clinical terminologies are essential to realizing the benefits of electronic health record systems. However, implementing consistent and sustainable use of terminology has proven to be both intellectually and practically challenging. First, this project derives a conceptual understanding of the scope and intricacies of the challenge by…

Validation of the professional practice environment scale in nurse educators in hospitals.

PubMed

Sayers, Jan Maree; Salamonson, Yenna; DiGiacomo, Michelle; Davidson, Patricia Mary

2016-03-01

To report an assessment of the psychometric properties of the Professional Practice Environment (PPE) scale in a sample of Australian nurse educators in acute care hospitals. Although nurse educators are important in an enabling work environment, there has been no reported exploration of their satisfaction with work in acute care hospitals. The factor structure and internal consistency of the PPE scale were consistent with Erickson's eight-factor model of the items, indicating the appropriateness of the scale as an assessment tool to measure the PPE of nurse educators. The PPE scale is useful for monitoring the work environment of nurse educators in clinical practice and the environmental effects influencing their recruitment, retention and job satisfaction. This work may inform the development of integrated professional practice environments where the professional practice and workplace satisfaction of nurse educators are optimised, influencing safe, quality patient care.

Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.

PubMed

2003-02-01

International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated criteria to assess the quality of guidelines. To develop and validate an international instrument for assessing the quality of the process and reporting of clinical practice guideline development. The instrument was developed through a multi-staged process of item generation, selection and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating countries were evaluated independently by 194 appraisers with the instrument. Following refinement the instrument was further field tested on three guidelines per country by a new set of 70 appraisers. The final version of the instrument contained 23 items grouped into six quality domains with a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, editorial independence). 95% of appraisers found the instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach's alpha 0.64-0.88). Guidelines produced as part of an established guideline programme had significantly higher scores on editorial independence and, after the publication of a national policy, had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical documentation had higher scores on that domain (p<0.0001). This is the first time an appraisal instrument for clinical practice guidelines has been developed and tested internationally. The instrument is sensitive to differences in important aspects of guidelines and can be used consistently and easily by a wide range of professionals from different backgrounds. The adoption of common standards should improve the consistency and quality of the reporting of guideline development worldwide and provide a framework to encourage international comparison of clinical practice guidelines.

Evidence-based practice guidelines for prescribing home modifications for clients with bariatric care needs.

PubMed

de Lange, Laura; Coyle, Emma; Todd, Helen; Williams, Cylie

2018-04-01

Home modifications maintain people's functional independence and safety. No literature exists to guide the prescription of home modifications for clients with bariatric care needs. With Australia's increasing obesity rate, more evidence is needed to support home modification prescribers. This study aimed to map Australian home modification prescribing practices for clients with bariatric care needs and to establish and evaluate a clinical resource for this prescription process. The study included two phases. Phase 1 conducted a cross-sectional survey of therapists practicing in Australia, and Australian industry partners who prescribe or install home modifications for clients with bariatric care needs. Phase 2 included design, implementation and evaluation of a clinical resource. Data were analysed with means and frequencies; multivariable regression analysis was used to explore prescribing habits. Therapists surveyed (n = 347) reported 11 different bariatric weight definitions. Less than 3% constantly or regularly prescribed home modifications for these clients; rails were most commonly prescribed. Many therapists (n = 171, 58%) 'never' or 'rarely' knew rail load capacity. Therapists' knowledge of rail load capacity was associated with previous experience prescribing home modifications (P = 0.009); rail manufacturer's advice (P = 0.016) and not using advice from builders (P = 0.001). Clinical resources were used by 11% (n = 26) of therapists to support their prescription, and industry sporadically relied on therapists to specify modification design requirements (n = 5, 45%). Post-implementation of a clinical resource increased consensus regarding understanding of the term bariatric and increased consultation with builders and manufacturers. There was a lack of consistency in bariatric terminology, uncertainty of rail load capacities and minimal use of clinical practice guidelines. Additional resources will assist with consistency in prescribing practices to maximise occupational performance for clients with bariatric care needs. © 2018 Occupational Therapy Australia.

Concordance Between Clinical Practice and Published Evidence: Findings From Virginia Commonwealth University School of Dentistry.

PubMed

Chiang, Harmeet K; Best, Al M; Sarrett, David C

2017-09-01

To evaluate the concordance between clinical practice and published evidence by dental faculty and graduating students of the Virginia Commonwealth University School of Dentistry. A questionnaire previously developed by the National Dental Practice-Based Research Network with 12 clinical scenarios was administered to VCU faculty and graduating students. Responses were scored as either consistent or inconsistent with published evidence and then analyzed for differences between dental faculty, graduating students, and the national results. There were 43 dental faculty members with at least half-time student contact who responded to the survey. Faculty concordance ranged from 33% to 100%, and general practice faculty had the highest concordance (82%). Eighty-five of the graduating class of 98 responded to the survey, and student concordance ranged from 18% to 92% and averaged 67%. General practice faculty had higher concordance with published evidence than recently graduated dental students. Graduating students and dental faculty demonstrated higher concordance with evidence-based practice than practitioners in the National Dental Practice-Based Research Network. General practice dental faculty demonstrated adequate concordance, but students demonstrated only a medium-level concordance. Practitioners involved in teaching dental students are better able to keep up with evolving evidence and are better able to demonstrate evidence-based practice. Copyright © 2017 Elsevier Inc. All rights reserved.

Rivaroxaban in patients with atrial fibrillation: from ROCKET AF to everyday practice.

PubMed

Barón-Esquivias, Gonzalo; Marín, Francisco; Sanmartín Fernandez, Marcelo

2017-05-01

Registries and non-interventional studies offer relevant and complementary information to clinical trials, since they have a high external validity. Areas covered: The information regarding the efficacy and safety of rivaroxaban compared with warfarin, or rivaroxaban alone in clinical practice was reviewed in this manuscript. For this purpose, a search on MEDLINE and EMBASE databases was performed. The MEDLINE and EMBASE search included both medical subject headings (MeSH) and keywords including: atrial fibrillation (AF) OR warfarin OR clinical practice OR ROCKET AF AND rivaroxaban. Case reports were not considered. Expert commentary: In ROCKET AF, rivaroxaban was at least as effective as warfarin for the prevention of stroke in patients with nonvalvular AF at high risk of stroke, but, importantly, with a lesser risk of intracranial, critical and fatal bleedings. A number of observational comparative and non-comparative studies, with more than 60,000 patients included treated with rivaroxaban, have analyzed the efficacy and safety of rivaroxaban in real-life patients with AF in different clinical settings. These studies have shown that in clinical practice, rates of stroke and major bleeding were consistently lower than those reported in ROCKET AF, likely due to the lower thromboembolic and bleeding risk observed in these patients.

Empowering clinical supervisors to flourish though critical companionship.

PubMed

Mackay, Maria; Stephens, Moira; Wragg, Siobhan; Ebejer, Saskia; Bourgeois, Sharon

2018-01-01

Education for professional nursing practice has undergone a significant shift over the last few decades impacting nursing practice and the relationship between nurses. Enhancing professional practice and acting as a conduit for empowering nurses to be active participants in their learning and development is Practice Development. This action research project with philosophical premises of critical companionship and human flourishing aimed to develop the knowledge and skills of registered nurses in their ability to provide clinical supervision of nursing students in practice. The overall project consisted of two action research cycles in two different health facilities. Participants in both projects identified similar issues and common learning needs including; how to better understand and develop skills in reflective practice; how to provide a positive learning and enabling environment; and how to provide effective solution focused feedback. Workshop facilitators witnessed the flourishing of participants as they were enabled to negotiate their learning requirements; grow and develop in their roles over the workshop series. Participants themselves identified personal growth in skills, knowledge and confidence in being a preceptor as a result of the workshops in the study. Overall, this study has resulted in the development and capacity building of the nursing workforce clinical placement capacity through the development of clinical supervisors. Copyright © 2017 Elsevier Ltd. All rights reserved.

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework

PubMed Central

Kontopantelis, Evangelos; Buchan, Iain; Reeves, David; Checkland, Kath; Doran, Tim

2013-01-01

Objectives To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system. Design Retrospective longitudinal study. Setting Data for 2007–2008 to 2010–2011, extracted from the clinical computer systems of general practices in England. Participants All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice. Main outcome measures Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement. Results Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels). Conclusions Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system. PMID:23913774

iMidwife: midwifery students' use of smartphone technology as a mediated educational tool in clinical environments.

PubMed

DeLeo, Annemarie; Geraghty, Sadie

2017-12-18

The increasing use of smartphone technology in health care provides midwifery students with unprecedented access to online resources that facilitates the optimal care of women and supports ongoing learning. A small pilot study was conducted in Western Australia, with 29 undergraduate and postgraduate midwifery students to explore the use of smartphone technology whilst in clinical practice. This study aimed to define the impact of smartphones in clinical decision-making and learning whilst in clinical areas, by midwifery students at the point of care. An online survey was used to collect data. Five consistent themes were identified from the results. Smartphone technology encourages self-directed learning, consolidation of theory, engagement through blended learning, complements online education in clinical practice and is a trend in the future of midwifery curriculum. Smartphones enhance the learning and mobility of supportive resources that consolidate midwifery students' clinical experience in workplace environments.

The effects of information framing on the practices of physicians.

PubMed

McGettigan, P; Sly, K; O'Connell, D; Hill, S; Henry, D

1999-10-01

The presentation format of clinical trial results, or the "frame," may influence perceptions about the worth of a treatment. The extent and consistency of that influence are unclear. We undertook a systematic review of the published literature on the effects of information framing on the practices of physicians. Relevant articles were retrieved using bibliographic and electronic searches. Information was extracted from each in relation to study design, frame type, parameter assessed, assessment scale, clinical setting, intervention, results, and factors modifying the frame effect. Twelve articles reported randomized trials investigating the effect of framing on doctors' opinions or intended practices. Methodological shortcomings were numerous. Seven papers investigated the effect of presenting clinical trial results in terms of relative risk reduction, or absolute risk reductions or the number needing to be treated; gain/loss (positive/negative) terms were used in four papers; verbal/numeric terms in one. In simple clinical scenarios, results expressed in relative risk reduction or gain terms were viewed most positively by doctors. Factors that reduced the impact of framing included the risk of causing harm, preexisting prejudices about treatments, the type of decision, the therapeutic yield, clinical experience, and costs. No study investigated the effect of framing on actual clinical practice. While a framing effect may exist, particularly when results are presented in terms of proportional or absolute measures of gain or loss, it appears highly susceptible to modification, and even neutralization, by other factors that influence doctors' decision making. Its effects on actual clinical practice are unknown.

Development of a Lifespan-Based Novel Composite Person-Reported Outcome Measure Using Data from the CINRG Duchenne Natural History Study

DTIC Science & Technology

2016-10-01

and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation. REPORT...Applicability: Well- designed CAT-PRO questionnaires can be used in both clinical trials and day-to-day clinical practice. For clinical trials, they provide...confirm that items are responsive to self-reported changes in milestone ability over a time period consistent with design of contemporary clinical

[Analysis of rational clinical uses of traditional Chinese medicine injections and factors influencing adverse drug reactions].

PubMed

Sun, Shi-Guang; Li, Zi-Feng; Xie, Yan-Ming; Liu, Jian; Lu, Yan; Song, Yi-Fei; Han, Ying-Hua; Liu, Li-Da; Peng, Ting-Ting

2013-09-01

To rationalize the clinical use and safety are some of the key issues in the surveillance of traditional Chinese medicine injections (TCMIs). In this 2011 study, 240 medical records of patients who had been discharged following treatment with TCMIs between 1 and 12 month previously were randomly selected from hospital records. Consistency between clinical use and the description of TCMIs was evaluated. Research on drug use and adverse drug reactions/events using logistic regression analysis was carried out. There was poor consistency between clinical use and best practice advised in manuals on TCMIs. Over-dosage and overly concentrated administration of TCMIs occurred, with the outcome of modifying properties of the blood. Logistic regression analysis showed that, drug concentration was a valid predictor for both adverse drug reactions/events and benefits associated with TCMIs. Surveillance of rational clinical use and safety of TCMIs finds that clinical use should be consistent with technical drug manual specifications, and drug use should draw on multi-layered logistic regression analysis research to help avoid adverse drug reactions/events.

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project): a clinical trial by clusters.

PubMed

Del Cura-González, Isabel; López-Rodríguez, Juan A; Sanz-Cuesta, Teresa; Rodríguez-Barrientos, Ricardo; Martín-Fernández, Jesús; Ariza-Cardiel, Gloria; Polentinos-Castro, Elena; Román-Crespo, Begoña; Escortell-Mayor, Esperanza; Rico-Blázquez, Milagros; Hernández-Santiago, Virginia; Azcoaga-Lorenzo, Amaya; Ojeda-Ruiz, Elena; González-González, Ana I; Ávila-Tomas, José F; Barrio-Cortés, Jaime; Molero-García, José M; Ferrer-Peña, Raul; Tello-Bernabé, María Eugenia; Trujillo-Martín, Mar

2016-05-17

Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6 months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6 months post-intervention, using 95 % confidence intervals. A linear multilevel regression will be used to adjust the model. The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. ClinicalTrials.gov: NCT02210442 .

Clinical terminology support for a national ambulatory practice outcomes research network.

PubMed

Ricciardi, Thomas N; Lieberman, Michael I; Kahn, Michael G; Masarie, F E

2005-01-01

The Medical Quality Improvement Consortium (MQIC) is a nationwide collaboration of 74 healthcare delivery systems, consisting of 3755 clinicians, who contribute de-identified clinical data from the same commercial electronic medical record (EMR) for quality reporting, outcomes research and clinical research in public health and practice benchmarking. Despite the existence of a common, centrally-managed, shared terminology for core concepts (medications, problem lists, observation names), a substantial "back-end" information management process is required to ensure terminology and data harmonization for creating multi-facility clinically-acceptable queries and comparable results. We describe the information architecture created to support terminology harmonization across this data-sharing consortium and discuss the implications for large scale data sharing envisioned by proponents for the national adoption of ambulatory EMR systems.

Clinical Terminology Support for a National Ambulatory Practice Outcomes Research Network

PubMed Central

Ricciardi, Thomas N.; Lieberman, Michael I.; Kahn, Michael G.; Masarie, F.E. “Chip”

2005-01-01

The Medical Quality Improvement Consortium (MQIC) is a nationwide collaboration of 74 healthcare delivery systems, consisting of 3755 clinicians, who contribute de-identified clinical data from the same commercial electronic medical record (EMR) for quality reporting, outcomes research and clinical research in public health and practice benchmarking. Despite the existence of a common, centrally-managed, shared terminology for core concepts (medications, problem lists, observation names), a substantial “back-end” information management process is required to ensure terminology and data harmonization for creating multi-facility clinically-acceptable queries and comparable results. We describe the information architecture created to support terminology harmonization across this data-sharing consortium and discuss the implications for large scale data sharing envisioned by proponents for the national adoption of ambulatory EMR systems. PMID:16779116

Driving out waste: a framework to enhance value in clinical care.

PubMed

Burton, David A

2013-06-01

Many healthcare providers today are seeking to improve the value of the care they deliver by implementing standardized clinical practice guidelines aimed at reducing variations in care, avoiding complications, and lowering costs. To succeed, such an initiative requires the full support and participation of the clinicians who will use the guidelines. Providers also should have a fully developed infrastructure consisting of a clinical content system, an analytics system, and a deployment system.

Dedicated education unit: student perspectives.

PubMed

Nishioka, Vicki M; Coe, Michael T; Hanita, Makoto; Moscato, Susan R

2014-01-01

The study compared students' perceptions of their clinical learning experiences in a dedicated education unit (DEU) with their experiences in traditional clinical education. Unlike traditional academic-instructor models, expert nurses in the DEU provide clinical education to students with faculty support. This repeated measures design used student surveys, supplemented by focus group data. Students were more likely to agree that their clinical learning experience was high quality and they had a consistent mentoring relationship during DEU rotations. Students also reported the quality of the unit's learning environment, the leadership style of the nurse manager, and the nursing care on the unit was more favorable in DEUs than traditional units. Consistent with their changed role in DEUs, faculty members were less active in helping students integrate theory and practice. These findings provide additional evidence of the value that the DEU model contributes to high-quality clinical education.

Clinical Nurse Leader Integration Into Practice: Developing Theory To Guide Best Practice.

PubMed

Bender, Miriam

2016-01-01

Numerous policy bodies have identified the clinical nurse leader (CNL) as an innovative new role for meeting higher health care quality standards. Although there is growing evidence of improved care environment and patient safety and quality outcomes after redesigning care delivery microsystems to integrate CNL practice, significant variation in CNL implementation has been noted across reports, making it difficult to causally link CNL practice to reported outcomes. This variability reflects the overall absence in the literature of a well-defined CNL theoretical framework to help guide standardized application in practice. To address this knowledge gap, an interpretive synthesis with a grounded theory analysis of CNL narratives was conducted to develop a theoretical model for CNL practice. The model clarifies CNL practice domains and proposes mechanisms by which CNL-integrated care delivery microsystems improve health care quality. The model highlights the need for a systematic approach to CNL implementation including a well-thought out strategy for care delivery redesign; a consistent, competency-based CNL workflow; and sustained macro-to-micro system leadership support. CNL practice can be considered an effective approach to organizing nursing care that maximizes the scope of nursing to influence the ways care is delivered by all professions within a clinical microsystem. Copyright © 2016 Elsevier Inc. All rights reserved.

Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery.

PubMed

Bender, Miriam; Williams, Marjory; Su, Wei; Hites, Lisle

2017-02-01

To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery. There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness. Sequential mixed methods. A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equation modelling were used to validate the measurement and model structure. Final sample n = 518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships. The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum. © 2016 John Wiley & Sons Ltd.

Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors.

PubMed

Vaughan-Graham, Julie; Cott, Cheryl

2017-10-01

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept. A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive. Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group. This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas. © 2016 John Wiley & Sons, Ltd.

Clinical practice guidelines consistency for patients with multimorbidity: a case-study in the management of type 2 diabetes and hypertension.

PubMed

Galopin, Alexandre; Bouaud, Jacques; Pereira, Suzanne; Séroussi, Brigitte

2015-01-01

Decision support for the guideline-based management of patients with multimorbidity is a challenge since it relies on the combination of single-disease clinical practice guidelines (CPGs). The aim of this work is to present a framework to check, at the modelling level, whether two CPGs overlap and are potentially inconsistent, thus requiring further reconciliation. The method relies on an ontological comparison of the patient profiles covered by CPGs and the recommended actions attached. It was applied to check the consistency of CPGs for the management of arterial hypertension and for the management of type 2 diabetes. Results showed that the two CPGs had only one common patient profile, although more profiles were impacted through profile subsumption. In this specific case, recommended actions were not found inconsistent since antihypertensive and anti-diabetic drugs could be combined in an additive way.

The evidence-practice gap in specialist mental healthcare: systematic review and meta-analysis of guideline implementation studies.

PubMed

Girlanda, Francesca; Fiedler, Ines; Becker, Thomas; Barbui, Corrado; Koesters, Markus

2017-01-01

Clinical practice guidelines are not easily implemented, leading to a gap between research synthesis and their use in routine care. To summarise the evidence relating to the impact of guideline implementation on provider performance and patient outcomes in mental healthcare settings, and to explore the performance of different strategies for guideline implementation. A systematic review of randomised controlled trials, controlled clinical trials and before-and-after studies comparing guideline implementation strategies v. usual care, and different guideline implementation strategies, in patients with severe mental illness. In total, 19 studies met our inclusion criteria. The studies did not show a consistent positive effect of guideline implementation on provider performance, but a more consistent small to modest positive effect on patient outcomes. Guideline implementation does not seem to have an impact on provider performance, nonetheless it may influence patient outcomes positively. © The Royal College of Psychiatrists 2017.

Confirmatory factor analysis of the Chinese Breast Cancer Screening Beliefs Questionnaire.

PubMed

Kwok, Cannas; Fethney, Judith; White, Kate

2012-01-01

Chinese women have been consistently reported as having low breast cancer screening practices. The Chinese Breast Cancer Screening Beliefs Questionnaire (CBCSB) was designed to assess Chinese Australian women's beliefs, knowledge, and attitudes toward breast cancer and screening practices. The objectives of the study were to confirm the factor structure of the CBCSB with a new, larger sample of immigrant Chinese Australian women and to report its clinical validity. A convenience sample of 785 Chinese Australian women was recruited from Chinese community organizations and shopping malls. Cronbach α was used to assess internal consistency reliability, and Amos v18 was used for confirmatory factor analysis. Clinical validity was assessed through linear regression using SPSS v18. The 3-factor structure of the CBCSB was confirmed, although the model required respecification to arrive at a suitable model fit as measured by the goodness-of-fit index (0.98), adjusted goodness-of-fit index (0.97), normed fit index (0.95), and root mean square error of approximation (0.031). Internal consistency reliability coefficients were satisfactory (>.6). Women who engaged in all 3 types of screening had more proactive attitudes to health checkups and perceived less barriers to mammographic screening. The CBCSB is a valid and reliable tool for assessing Chinese women's beliefs, knowledge, and attitudes about breast cancer and breast cancer screening practices. The CBCSB can be used for providing practicing nurses with insights into the provision of culturally sensitive breast health education.

Mental workload as a key factor in clinical decision making.

PubMed

Byrne, Aidan

2013-08-01

The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive based practice. The purpose of this paper is to introduce the concept of mental workload as a key determinant of the type of cognitive processing used by clinicians. Published research appears to be consistent with 'schemata' based cognition as the principle mode of working for those engaged in complex tasks under time pressure. Although conscious processing of factual data is also used, it may be the primary mode of cognition only in situations where time pressure is not a factor. Further research on the decision making process should be based on outcomes which are not dependant on conscious recall of past actions or events and include a measure of mental workload. This further appears to support the concept of the patient, within the clinical environment, as the most effective learning resource.

Use of clinical practice guidelines by dentists: findings from the Japanese dental practice-based research network.

PubMed

Kakudate, Naoki; Yokoyama, Yoko; Sumida, Futoshi; Matsumoto, Yuki; Gordan, Valeria V; Gilbert, Gregg H

2017-02-01

The objectives of this study were to: (1) examine differences in the use of dental clinical practice guidelines among Japanese dentists, and (2) identify characteristics associated with the number of guidelines used by participating dentists. We conducted a cross-sectional study consisting of a questionnaire survey in Japan between July 2014 and May 2015. The study queried dentists working in outpatient dental practices who are affiliated with the Dental Practice-Based Research Network Japan (n = 148). They were asked whether they have used each of 15 Japanese dental clinical guidelines. Associations between the number of guidelines used by participants and specific characteristics were analysed via negative binomial regression analysis. The mean number of guidelines used by participating dentists was 2.5 ± 2.9 [standard deviation (SD)]. Rate of use of guidelines showed substantial variation, from 5% to 34% among dentists. The proportion of dentists that used guidelines was the highest among oral medicine specialists, who had the highest proportion for 10 of 15 guidelines. Negative binomial regression analysis identified three factors significantly associated with the number of guidelines used: 'years since graduation from dental school', 'specialty practice' and 'practice busyness'. These results suggest that the use of clinical practice guidelines by Japanese dentists may still be inadequate. Training in the use of the guidelines could be given to dental students as undergraduate education and to young clinicians as continuing education. © 2016 John Wiley & Sons, Ltd.

Form Follows Function: A Model for Clinical Supervision of Genetic Counseling Students.

PubMed

Wherley, Colleen; Veach, Patricia McCarthy; Martyr, Meredith A; LeRoy, Bonnie S

2015-10-01

Supervision plays a vital role in genetic counselor training, yet models describing genetic counseling supervision processes and outcomes are lacking. This paper describes a proposed supervision model intended to provide a framework to promote comprehensive and consistent clinical supervision training for genetic counseling students. Based on the principle "form follows function," the model reflects and reinforces McCarthy Veach et al.'s empirically derived model of genetic counseling practice - the "Reciprocal Engagement Model" (REM). The REM consists of mutually interactive educational, relational, and psychosocial components. The Reciprocal Engagement Model of Supervision (REM-S) has similar components and corresponding tenets, goals, and outcomes. The 5 REM-S tenets are: Learning and applying genetic information are key; Relationship is integral to genetic counseling supervision; Student autonomy must be supported; Students are capable; and Student emotions matter. The REM-S outcomes are: Student understands and applies information to independently provide effective services, develop professionally, and engage in self-reflective practice. The 16 REM-S goals are informed by the REM of genetic counseling practice and supported by prior literature. A review of models in medicine and psychology confirms the REM-S contains supervision elements common in healthcare fields, while remaining unique to genetic counseling. The REM-S shows promise for enhancing genetic counselor supervision training and practice and for promoting research on clinical supervision. The REM-S is presented in detail along with specific examples and training and research suggestions.

"People like numbers": a descriptive study of cognitive assessment methods in clinical practice for Aboriginal Australians in the Northern Territory.

PubMed

Dingwall, Kylie M; Pinkerton, Jennifer; Lindeman, Melissa A

2013-01-31

Achieving culturally fair assessments of cognitive functioning for Aboriginal people is difficult due to a scarcity of appropriately validated tools for use with this group. As a result, some Aboriginal people with cognitive impairments may lack fair and equitable access to services. The objective of this study was to examine current clinical practice in the Northern Territory regarding cognitive assessment for Aboriginal people thereby providing some guidance for clinicians new to this practice setting. Qualitative enquiry was used to describe practice context, reasons for assessment, and current practices in assessing cognition for Aboriginal Australians. Semi-structured interviews were conducted with 22 clinicians working with Aboriginal clients in central and northern Australia. Results pertaining to assessment methods are reported. A range of standardised tests were utilised with little consistency across clinical practice. Nevertheless, it was recognised that such tests bear severe limitations, requiring some modification and significant caution in their interpretation. Clinicians relied heavily on informal assessment or observations, contextual information and clinical judgement. Cognitive tests developed specifically for Aboriginal people are urgently needed. In the absence of appropriate, validated tests, clinicians have relied on and modified a range of standardised and informal assessments, whilst recognising the severe limitations of these. Past clinical training has not prepared clinicians adequately for assessing Aboriginal clients, and experience and clinical judgment were considered crucial for fair interpretation of test scores. Interpretation guidelines may assist inexperienced clinicians to consider whether they are achieving fair assessments of cognition for Aboriginal clients.

A Leadership Education and Development Program for Clinical Nurses.

PubMed

Fitzpatrick, Joyce J; Modic, Mary Beth; Van Dyk, Jennifer; Hancock, K Kelly

2016-11-01

The Leadership Education and Development (LEAD) Program was designed to transform care at the bedside by empowering clinical nurses as leaders. The heart of LEAD was enhancing communication skills of clinical nurses with clinical colleagues and, most importantly, patients and families. Key concepts of leadership/management were included: personal awareness, personal leadership skills/abilities, leading change, leading others individually and in teams, enhancing the patient/provider experience, and the leadership role in outcomes management. A quantitative, longitudinal, survey design was used with 2 cohorts. The program consisted of six 4-hour sessions for 3 to 6 months. Leadership practices were measured before program implementation, at the end of the program, and 3 months after program completion. There were significant increases in leadership practices sustained 3 months after program completion. A range of other outcome measures was included. There is a need for additional leadership development programs for clinical nurses.

Situational Analysis of Physical Therapist Clinical Instructors' Facilitation of Students' Emerging Embodiment of Movement in Practice.

PubMed

Covington, Kyle; Barcinas, Susan J

2017-06-01

Physical therapists improve the functional ability of patients after injury and disease. A unique component of their practice is the ability to use the movement of their own bodies to effect change in their patients. This ability has been recognized as a distinctive attribute of expert physical therapists. The purpose of this qualitative situational analysis study was to examine how physical therapist clinical instructors perceive and facilitate their students' emerging integration of movement in practice. Data collection and analysis were guided by a theoretical framework for understanding "professional ways of being." Data were analyzed using coding and mapping strategies consistent with situational analysis techniques. The study included 5 physical therapist clinical instructors and their respective 5 physical therapist students. Data were collected during beginning, midterm, and final weeks of the students' clinical internships using participant interviews, observation, and document analysis. Coded data were summarized using situational analysis mapping strategies, resulting in 11 maps. These maps were further analyzed and reduced to 5 thematic behaviors enacted by a clinical instructor as he or she helps facilitate students' use of movement in practice. These behaviors are adapt, prepare, enhance, connect , and develop . The limited number of participants and the relative homogeneity of the student sample may have limited the diversity of data collected. The 5 behaviors are useful when considered as a trajectory of development. To our knowledge, this study marks the first description of how physical therapist clinical instructors develop students' use of movement in practice and how to enact behaviors important in students' continued professional development. The findings are important for clinical instructors and academic programs considering how best to prepare students to use movement and develop their skills early in practice. © 2017 American Physical Therapy Association

Developing clinical practice guidelines for Chinese herbal treatment of polycystic ovary syndrome: A mixed-methods modified Delphi study.

PubMed

Lai, Lily; Flower, Andrew; Moore, Michael; Lewith, George

2015-06-01

Preliminary evidence suggests Chinese herbal medicine (CHM) could be a viable treatment option for polycystic ovary syndrome (PCOS). Prior to conducting a clinical trial it is important to consider the characteristics of good clinical practice. This study aims to use professional consensus to establish good clinical practice guidelines for the CHM treatment of PCOS. CHM practitioners participated in a mixed-methods modified Delphi study involving three rounds of structured group communication. Round 1 involved qualitative interviews with practitioners to generate statements regarding good clinical practice. In round 2, these statements were distributed online to the same practitioners to rate their agreement using a 7-point Likert scale, where group consensus was defined as a median rating of ≥5. Statements reaching consensus were accepted for consideration onto the guideline whilst those not reaching consensus were re-distributed for consideration in round 3. Statements presented in the guidelines were graded from A (strong consensus) to D (no consensus) determined by median score and interquartile range. 11 CHM practitioners in the UK were recruited. After three Delphi rounds, 91 statement items in total had been considered, of which 89 (97.8%) reached consensus and 2 (2.2%) did not. The concluding set of guidelines consists of 85 items representing key features of CHM prescribing for PCOS. These guidelines can be viewed as an initial framework that captures fundamental principles of good clinical practice for CHM. Copyright © 2015 Elsevier Ltd. All rights reserved.

A rational approach to the selection of useful drugs for clinical practice.

PubMed

Spector, Reynold; Vesell, Elliot S

2002-05-01

Confusion exists concerning optimal selection of drugs for clinical practice. Many reasons contribute to this confusion which derives from various sources including industry, the FDA and often less than ideal education of physicians in clinical pharmacology during medical school and thereafter. This presentation does not focus on allocating blame for the current unsatisfactory situation, but rather offers a solution to improve drug therapy. Our educational solution consists of a paradigm for rational drug therapy, specifically a checklist of eight criteria for physicians to review before prescribing drugs. Such a review would facilitate better estimation by physicians of risk/benefit ratios involving new, often expensive and, in some cases, questionably effective and safe drugs. Copyright 2002 S. Karger AG, Basel

Knowledge enabled plan of care and documentation prototype.

PubMed

DaDamio, Rebecca; Gugerty, Brian; Kennedy, Rosemary

2006-01-01

There exist significant challenges in integrating the plan of care into documentation and point of care operational processes. A plan of care is often a static artifact that meets regulatory standards with limited influence on supporting goal-directed care delivery processes. Although this prototype is applicable to many clinical disciplines, we will highlight nursing processes in demonstrating a knowledge-driven computerized solution that fully integrates the plan of care within documentation. The knowledge-driven solution reflects evidenced-based practice; is an effective tool for managing problems, orders/interventions, and the patient's progress towards expected outcomes; meets regulatory standards; and drives quality and process improvement. The knowledge infrastructure consists of fully represented terminology, structured clinical expressions utilizing the controlled terminology and clinical knowledge representing evidence-based practice.

A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis

PubMed Central

Pencharz, James N; Grigoriadis, Elizabeth; Jansz, Gwenderlyn F; Bombardier, Claire

2002-01-01

Clinical practice guidelines are important tools to assist clinical decision-making. Recently, several guidelines addressing the management of osteoarthritis (OA) have been published. Clinicians treating patients with OA must ensure that these guidelines are developed with consistency and methodological rigour. We undertook a qualitative summary and critical appraisal of six medical treatment guidelines for the management of lower-limb OA published in the medical literature within the past 5 years. A review of these six guidelines revealed that each possesses strengths and weakness. While most described the scope and intended patient populations, the guidelines varied considerably in the rigour of their development, coverage of implementation issues, and disclosure of conflicts of interest. PMID:11879536

[Development and application of emergency medical information management system].

PubMed

Wang, Fang; Zhu, Baofeng; Chen, Jianrong; Wang, Jian; Gu, Chaoli; Liu, Buyun

2011-03-01

To meet the needs of clinical practice of rescuing critical illness and develop the information management system of the emergency medicine. Microsoft Visual FoxPro, which is one of Microsoft's visual programming tool, is used to develop computer-aided system included the information management system of the emergency medicine. The system mainly consists of the module of statistic analysis, the module of quality control of emergency rescue, the module of flow path of emergency rescue, the module of nursing care in emergency rescue, and the module of rescue training. It can realize the system management of emergency medicine and,process and analyze the emergency statistical data. This system is practical. It can optimize emergency clinical pathway, and meet the needs of clinical rescue.

Psychiatric mental health evidence-based practice.

PubMed

Rice, Michael J

2008-05-01

This article is the first in a new column focusing on evidence-based practice (EBP) in psychiatric mental health nursing. The EBP movement was strongly influenced by a British epidemiologist, Dr. Cochrane, who advocated care based on randomized clinical controlled trials in the late 1900s. Although the majority of the EBP movement is directed toward developing clinical guidelines, the critical element focuses on the therapeutic relationship and clinical judgment associated with providing care. This column will address a clinical problem, define PICO questions, report knowledge base searches, and present existing evidence. Recommendations will be offered for potential interventions and suggestions for evaluating clinical outcomes. Nurses can no longer view clinical studies as academic exercises discarded on graduation and not applied to the clinical setting. Conscientiously applying what is known about treatments and interventions of ethical, if not legal, value is consistent with the professional definition of care. J Am Psychiatr Nurses Assoc, 2008; 14(2), 107-111. DOI: 10.1177/1078390308315798.

Exploring the perception of nursing students about consequences of reflection in clinical settings

PubMed Central

Karimi, Shahnaz; Haghani, Fariba; Yamani, Nikoo; Kalyani, Majid Najafi

2017-01-01

Background Reflection on practical experiences is a key element that enables students to recognize their own strengths and weaknesses and develop nursing skills. Whilst reflection may enhance students’ learning in practice, there is little evidence about nursing students’ perception of the consequences of reflection in clinical settings. Objective This study aimed to explore Iranian nursing students’ perception regarding the consequences of reflection during clinical practices. Methods This qualitative study was conducted by a conventional content analysis approach in two nursing schools at Shiraz and Fasa Universities of Medical Sciences in Iran. Data were collected through in-depth semi-structured interviews during 2015–2016, from 20 students selected by purposive sampling. All the interviews were tape-recorded, transcribed verbatim, and analyzed by content analysis method. Rigor of this study was approved by member check and external audit. Results Two categories emerged from the data analysis, including movement toward professionalism and self-actualization of emotions. The former consisted of three subcategories of function modification, sharing experiences and generalizing experiences. The latter consisted of two subcategories of inner satisfaction and peace of mind. Conclusion The results indicated that nursing students’ reflection in clinical settings is effective in personal and professional levels. Reflection in a personal level led to positive emotions that increased the quality of care in patients. Accordingly, nursing educators need to create a nurturing climate as well as supporting reflective behaviors of nursing students. PMID:29038696

An analysis of Australian graduate critical care nurse education.

PubMed

Gill, Fenella J; Leslie, Gavin D; Grech, Carol; Latour, Jos M

2015-01-01

Preparation of specialist critical care nurses in Australia is at graduate level, although there remains considerable variation in courses offered in relation to qualification, content, assessment and outcomes. As higher education providers must now comply with the Australian Qualifications Framework (AQF) a study was conducted to examine existing critical care courses and graduate practice outcomes. Twenty-two critical care courses were reviewed. Data sources included course provider, websites, course curricula and telephone interviews with course coordinators. A framework approach, was used consisting of five key stages: preliminary immersion of raw data, conceptualising a thematic framework, indexing, charting, mapping and interpretation of data. Analysis revealed considerable variations in course delivery and graduate practice outcomes. Most courses used professional competency standards as a framework for course curricula and clinical assessment, with inconsistency in their translation to graduate practice outcomes. Twenty-one courses included clinical assessment at graduate certificate level with no clinical assessment conducted at master level. The expected practice outcome for fifteen courses was safe practice with graduates not expected to practice at a specialist or team leadership level. Minimum graduate practice standards were not included in three courses as an expected outcome. The AQF requires graduate nurse education to be compliant with academic outcome standards. The findings of our study indicate variations between courses and subsequent graduate practice outcomes. It is therefore timely to establish national critical care education graduate practice standards.

Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis.

PubMed

Hoffman, Steven J; Guindon, G Emmanuel; Lavis, John N; Randhawa, Harkanwal; Becerra-Posada, Francisco; Dejman, Masoumeh; Falahat, Katayoun; Malek-Afzali, Hossein; Ramachandran, Parasurama; Shi, Guang; Yesudian, C A K

2016-05-04

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices "often or very often" (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful. © The American Society of Tropical Medicine and Hygiene.

Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis

PubMed Central

Hoffman, Steven J.; Guindon, G. Emmanuel; Lavis, John N.; Randhawa, Harkanwal; Becerra-Posada, Francisco; Dejman, Masoumeh; Falahat, Katayoun; Malek-Afzali, Hossein; Ramachandran, Parasurama; Shi, Guang; Yesudian, C. A. K.

2016-01-01

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices “often or very often” (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful. PMID:26903613

Dose Adjustment for Normal Eating (DAFNE) in routine clinical practice: who benefits?

PubMed

Keen, A J A; Duncan, E; McKillop-Smith, A; Evans, N D; Gold, A E

2012-05-01

To explore the effectiveness of Dose Adjustment for Normal Eating in routine clinical practice in the UK. Participants were 124 adults with Type 1 diabetes who had completed a Dose Adjustment for Normal Eating course. Data were collected before the course and again 1 year later on a variety of biological, psychological and social measures. There were a range of significant benefits consistent with Dose Adjustment for Normal Eating aims, including: better control among those with baseline HbA(1c) ≥ 81 mmol/mol (9.6%) (z = -2.8, P = 0.004); reduced number of participants reporting severe hypoglycaemia (χ² = 4.27, P = 0.039); total eradication of diabetic ketoacidosis (χ² = 4.17, P = 0.041) and lower diabetes-related distress (z = -4.5, P < 0.001). The most deprived of the clinic population were significantly under-represented (χ² = 17.8, P = 0.001) and the levels of clinical depression were unusually low. These results indicate that Dose Adjustment for Normal Eating delivered in routine clinical practice is associated with a range of benefits and that certain clinical and psychosocial characteristics are associated with better outcomes. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

PubMed Central

Rajavi, Zhale; Safi, Sare; Javadi, Mohammad Ali; Azarmina, Mohsen; Moradian, Siamak; Entezari, Morteza; Nourinia, Ramin; Ahmadieh, Hamid; Shirvani, Armin; Shahraz, Saeid; Ramezani, Alireza; Dehghan, Mohammad Hossein; Shahsavari, Mohsen; Soheilian, Masoud; Nikkhah, Homayoun; Ziaei, Hossein; Behboudi, Hasan; Farrahi, Fereydoun; Falavarjani, Khalil Ghasemi; Parvaresh, Mohammad Mehdi; Fesharaki, Hamid; Abrishami, Majid; Shoeibi, Nasser; Rahimi, Mansour; Javadzadeh, Alireza; Karkhaneh, Reza; Riazi-Esfahani, Mohammad; Manaviat, Masoud Reza; Maleki, Alireza; Kheiri, Bahareh; Golbafian, Faegheh

2016-01-01

Purpose: To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population. Methods: Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9. Results: Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence. Conclusion: This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy. PMID:27994809

Experience with Fingolimod in Clinical Practice

PubMed Central

Hersh, Carrie M.; Hara-Cleaver, Claire; Rudick, Richard A.; Cohen, Jeffrey A.; Bermel, Robert A.; Ontaneda, Daniel

2015-01-01

Aim To report experience with fingolimod in clinical practice. Design/Methods Patients in an academic medical center who were prescribed fingolimod from October 2010 to August 2011 were identified through the electronic medical record and followed for 12 months after fingolimod initiation. Adverse effects, clinical measures, MRI data, and quality of life measures were assessed. Results Three hundred seventeen patients started fingolimod. Eleven patients were treatment naïve (3.5%) and 76 (24.0%) had remote disease modifying therapy use prior to fingolimod. One hundred fifty-one (47.6%) switched because of patient preference and 79 (24.9%) switched because of breakthrough disease. About 11.6% transitioned from natalizumab. Follow-up data were available for 306 patients (96.5%) with mean follow-up time 332 days. Fingolimod was discontinued in 76 of 306 patients (24.8%) at mean 248 days after fingolimod start. Discontinuation most often was due to adverse effects (n=40) or breakthrough disease (n=22). Among patients who started fingolimod with available 12 month follow-up data, 267 (87.3%) remained relapse free and 256 (83.7%) had no relapses or gadolinium enhancement. Time to first relapse occurred at mean 282 days after fingolimod initiation. Quality of life measures remained stable at follow-up. Conclusions Fingolimod was discontinued at a higher rate in clinical practice than in clinical trials. Discontinuation was primarily due to adverse effects or breakthrough disease. Disease activity was adequately controlled in most patients who started fingolimod. This clinical practice cohort is consistent with efficacy data from phase 3 trials and describes the most common tolerability issues in clinical practice. PMID:25271798

The marginalisation of dreams in clinical psychological practice.

PubMed

Leonard, Linda; Dawson, Drew

2018-04-22

The longstanding human interest in dreams has led to a significant body of psychological and philosophical discourse, including research. Recently, however, dreams have been relegated to the periphery of clinical psychological practice. This is potentially problematic as clients continue to bring dreams to therapy and many psychologists lack the confidence or competence to respond effectively to dream material. Building on the structural, professional and research cultures surrounding psychology using a cultural-historical activity theory framework, we argue the marginalisation of dreams is due to cultural-historical factors. These factors include the political and economic context in which psychology developed; psychology's early attempts to differentiate from psychoanalysis by identifying with behaviourism and the natural sciences; and a discipline-specific definition of what constitutes evidence-based practice. These factors led to professional discourses within which dreams are seen as of little clinical or therapeutic value, or that dream work is only for long-term therapy and requires extensive therapist training. However, there are diverse models of dream work consistent with most theoretical orientations within contemporary psychological practice. We conclude with recommendations on how to rebuild clinical confidence and competence in the use of dream material within the current professional environment. Copyright © 2018 Elsevier Ltd. All rights reserved.

A Comparison of the Concurrent and Predictive Validity of Three Measures of Readiness to Change Alcohol Use in a Clinical Sample of Adolescents

ERIC Educational Resources Information Center

Maisto, Stephen A.; Krenek, Marketa; Chung, Tammy; Martin, Christopher S.; Clark, Duncan; Cornelius, Jack

2011-01-01

The authors compared 3 measures of readiness to change alcohol use commonly used in clinical research and practice with adolescents: the Readiness Ruler, the SOCRATES (subscales of Recognition and Taking Steps), and a Staging Algorithm. The analysis sample consisted of 161 male and female adolescents presenting for intensive outpatient…

The context & clinical evidence for common nursing practices during labor.

PubMed

Simpson, Kathleen Rice

2005-01-01

The purpose of this article is to review the context and current evidence for common nursing care practices during labor and birth. Although many nursing interventions during labor and birth are based on physician orders, there are a number of care processes that are mainly within the realm of nursing practice. In many cases, particularly in community hospitals, routine physician orders for intrapartum care provide wide latitude for nurses in how they ultimately carry out those orders. An important consideration of common nursing practices during labor is the context or practice model in which those practices occur. Nursing practice is not the same in all clinical environments. Intrapartum nursing practice consists of an assortment of different roles depending on the circumstances, hospital setting, and context in which it takes place. A variety of intrapartum nursing practice models have evolved as a result and in response to the range of sizes, locations, and provider practice styles found in hospitals providing obstetric services. A summary of intrapartum nursing models is presented. The evidence is reviewed for the three most common clinical practices for which nurses have primary responsibility in most settings and that comprise the majority of their time in caring for women during labor: (1) maternal-fetal assessment, (2) management of oxytocin infusions, and (3) second-stage care. Evidence exists for these nursing interventions that can be used to promote maternal-fetal well-being, minimize risk, and enhance patient safety.

Active Duty - U.S. Army Noise Induced Hearing Injury Surveillance, Calendar Years 2007-2011

DTIC Science & Technology

2013-01-01

evaluation of public health practice ” (World Health Organization, 2013). By definition, surveillance systems include the capacity for data collection...until 2005 and it took 2 years before clinicians started using these guidelines more consistently in clinical practice . Data Description: The relative...the Army since September 2006 when the Medical Protection System’s (MEDPROS) Hearing Readiness Module ( HRM ) was implemented and compliance with the

Variations in patient safety climate and perceived quality of collaboration between professions in out-of-hours care

PubMed Central

Klemenc-Ketis, Zalika; Deilkås, Ellen Tveter; Hofoss, Dag; Bondevik, Gunnar Tschudi

2017-01-01

Purpose To get an overview of health care workers perceptions of patient safety climates and the quality of collaboration in Slovenian out-of-hours health care (OOHC) between professional groups. Materials and methods This was a cross-sectional study carried out in all (60) Slovenian OOHC clinics; 37 (61.7%) agreed to participate with 438 employees. The questionnaire consisted of the Slovenian version of the Safety Attitudes Questionnaire – Ambulatory Version (SAQ-AV). Results The study sample consisted of 175 (70.0%) physicians, nurse practitioners, and practice nurses. Practice nurses reported the highest patient safety climate scores in all dimensions. Total mean (standard deviation) SAQ-AV score was 60.9±15.2. Scores for quality of collaboration between different professional groups were high. The highest mean scores were reported by nurse practitioners on collaboration with practice nurses (4.4±0.6). The lowest mean scores were reported by practice nurses on collaboration with nurse practitioners (3.8±0.9). Conclusion Due to large variations in Slovenian OOHC clinics with regard to how health care workers from different professional backgrounds perceive safety culture, more attention should be devoted to improving the team collaboration in OOHC. A clearer description of professional team roles should be provided. PMID:29184416

A systematic review of recent clinical practice guidelines and best practice statements for the evaluation of the infertile male.

PubMed

Esteves, Sandro C; Chan, Peter

2015-09-01

We systematically identified and reviewed the methods and consistency of recommendations of recently developed clinical practice guidelines (CPG) and best practice statements (BPS) on the evaluation of the infertile male. MEDLINE and related engines as well as guidelines' Web sites were searched for CPG and BPS written in English on the general evaluation of male infertility published between January 2008 and April 2015. Four guidelines were identified, all of which reported to have been recently updated. Systematic review was not consistently used in the BPS despite being reported in the CPG. Only one of them reported having a patient representative in its development team. The CPG issued by the European Association of Urology (EAU) graded some recommendations and related that to levels (but not quality) of evidence. Overall, the BPS issued respectively by the American Urological Association and American Society for Reproductive Medicine concurred with each other, but both differed from the EAU guidelines with regard to methods of collection, extraction and interpretation of data. None of the guidelines incorporated health economics. Important specific limitations of conventional semen analysis results were ignored by all guidelines. Besides variation in the methodological quality, implementation strategies were not reported in two out of four guidelines. While the various panels of experts who contributed to the development of the CPG and BPS reviewed should be commended on their tremendous efforts aiming to establish a clinical standard in both the evaluation and management of male infertility, we recognized inconsistencies in the methodology of their synthesis and in the contents of their final recommendations. These discrepancies pose a barrier in the general implementation of these guidelines and may limit their utility in standardizing clinical practice or improving health-related outcomes. Continuous efforts are needed to generate high-quality evidence to allow further development of these important guidelines for the evaluation and management of males suffering from infertility.

The core role of the nurse practitioner: practice, professionalism and clinical leadership.

PubMed

Carryer, Jenny; Gardner, Glenn; Dunn, Sandra; Gardner, Anne

2007-10-01

To draw on empirical evidence to illustrate the core role of nurse practitioners in Australia and New Zealand. Enacted legislation provides for mutual recognition of qualifications, including nursing, between New Zealand and Australia. As the nurse practitioner role is relatively new in both countries, there is no consistency in role expectation and hence mutual recognition has not yet been applied to nurse practitioners. A study jointly commissioned by both countries' Regulatory Boards developed information on the core role of the nurse practitioner, to develop shared competency and educational standards. Reporting on this study's process and outcomes provides insights that are relevant both locally and internationally. This interpretive study used multiple data sources, including published and grey literature, policy documents, nurse practitioner program curricula and interviews with 15 nurse practitioners from the two countries. Data were analysed according to the appropriate standard for each data type and included both deductive and inductive methods. The data were aggregated thematically according to patterns within and across the interview and material data. The core role of the nurse practitioner was identified as having three components: dynamic practice, professional efficacy and clinical leadership. Nurse practitioner practice is dynamic and involves the application of high level clinical knowledge and skills in a wide range of contexts. The nurse practitioner demonstrates professional efficacy, enhanced by an extended range of autonomy that includes legislated privileges. The nurse practitioner is a clinical leader with a readiness and an obligation to advocate for their client base and their profession at the systems level of health care. A clearly articulated and research informed description of the core role of the nurse practitioner provides the basis for development of educational and practice competency standards. These research findings provide new perspectives to inform the international debate about this extended level of nursing practice. The findings from this research have the potential to achieve a standardised approach and internationally consistent nomenclature for the nurse practitioner role.

Best practices in nursing homes. Clinical supervision, management, and human resource practices.

PubMed

Dellefield, Mary Ellen

2008-07-01

Human resource practices including supervision and management are associated with organizational performance. Evidence supportive of such an association in nursing homes is found in the results of numerous research studies conducted during the past 17 years. In this article, best practices related to this topic have been culled from descriptive, explanatory, and intervention studies in a range of interdisciplinary research journals published between 1990 and 2007. Identified best practices include implementation of training programs on supervision and management for licensed nurses, certified nursing assistant job enrichment programs, implementation of consistent nursing assignments, and the use of electronic documentation. Organizational barriers and facilitators of these best practices are described. Copyright 2009, SLACK Incorporated.

Non-surgical care in patients with hip or knee osteoarthritis is modestly consistent with a stepped care strategy after its implementation.

PubMed

Smink, Agnes J; Bierma-Zeinstra, Sita M A; Schers, Henk J; Swierstra, Bart A; Kortland, Joke H; Bijlsma, Johannes W J; Teerenstra, Steven; Voorn, Theo B; Dekker, Joost; Vliet Vlieland, Thea P M; van den Ende, Cornelia H M

2014-08-01

To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care. A 2-year observational prospective cohort study. General practices in the region of Nijmegen in the Netherlands. Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP). Multifaceted interventions were developed to implement the strategy. Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments. Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS in 58% of the patients, which was mainly caused by the underuse of lifestyle advice and dietary therapy. In 57% of the consultations, the patient reported to have been advised to make a follow-up appointment. No determinants that influenced all three aspects of care were identified. Consistency with the SCS was found in about half of the patients for each of the three aspects of care. Health care can be further optimized by encouraging GP s to use X-rays more appropriately and to make more use of lifestyle advice, dietary therapy and follow-up appointments. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims.

PubMed

Simpson, Kathleen Rice; Kortz, Carol C; Knox, G Eric

2009-11-01

To achieve the goal of safe care for mothers and infants during labor and birth, Catholic Healthcare Partners (CHP; Cincinnati) conducted on-site risk assessments at the 16 hospitals with perinatal units in 2004-2005, with follow-up visits in 2006 through 2008. ON-SITE RISK ASSESSMENTS: In addition to assessing overall organizational risk, the assessments provided each hospital a gap analysis demonstrating up-to-date and outdated practices and strategies and resources necessary to make all practices consistent with current evidence and national guidelines and standards. CRITICAL ASPECTS OF CLINICAL CARE: Review of claims and near-miss data indicate that fetal assessment, labor induction, and second-stage labor care comprise the majority of risk of perinatal harm. Therefore, these clinical areas were the focus of strategies to promote safety. To promote consistency in knowledge and practice, in 2004 a variety of strategies were recommended, including interdisciplinary fetal monitoring education and routine medical record reviews to monitor ongoing adherence to appropriate practice and documentation. Success in implementing essential structural and process components of the perinatal patient safety program have resulted in improvement from 2003 to 2008 in specific outcomes for the 16 perinatal units surveyed, including reduction of perinatal harm, number of claims, and costs of claims. The program continues to evolve with modifications as needed as more evidence becomes available to guide best perinatal practices and new guidelines/standards are published. A patient safety program guided and supported by a health care system can result in safer clinical environments in individual hospitals and in decreased risk of preventable perinatal harm and liability costs.

Factors defining the mentoring competencies of clinical midwives: An exploratory quantitative research study in Japan.

PubMed

Hishinuma, Yuri; Horiuchi, Shigeko; Yanai, Haruo

2016-01-01

Clinical education is an extremely important process in cultivating healthcare professionals, and the quality of educators has a major impact on the quality of future practitioners. Although practicing clinical midwives contribute to the education of pre-registered midwives and those qualified within the past year (new midwives), the factors defining the educational competencies of clinical midwives have not been clarified. The purpose of this study was to explore the factors that define the mentoring competencies of clinical midwives involved in educating new midwives. An exploratory quantitative research study. Questionnaires were distributed to 694 midwives who had previously conducted educational activities with new midwives at the 63 facilities whose administrator or nurse manager in charge of all staff, including midwives, consented to participate. Of the 694 midwives, 464 (66.9%) returned the questionnaire and 451 (65.1%) valid responses were analyzed. Exploratory factor analyses were performed on the following three concepts: [competency as a professional], [competency as an educator], and [personal characteristics]. [Competency as a professional] consisted of two factors: and ; [competency as an educator] consisted of four factors: , , and ; and [personal characteristics consisted of three factors: , and . These three concepts were defined by a total of nine sub-concepts (factors), and 41 items were extracted with a reliability coefficient (Cronbach's α) of 0.944 CONCLUSIONS: "Mentoring competencies of clinical midwives (MCCM)" are defined by three concepts and nine sub-concepts, which can be evaluated by 41 items regarding the behavior, thoughts, and characteristics that clinical midwives exhibit when they educate new midwives in clinical settings. Copyright © 2015 Elsevier Ltd. All rights reserved.

Auditing the Immunization Data Quality from Routine Reports in Shangyu District, East China

PubMed Central

Hu, Yu; Zhang, Xinpei; Li, Qian; Chen, Yaping

2016-01-01

Objective: To evaluate the immunization data quality in Shangyu District, East China. Methods: An audit for immunization data for the year 2014 was conducted in 20 vaccination clinics of Shangyu District. The consistency of immunization data was estimated by verification factors (VFs), which was the proportion of vaccine doses reported as being administered that could be verified by written documentation at vaccination clinics. The quality of monitoring systems was evaluated using the quality index (QI). Results: The VFs of 20 vaccine doses ranged from 0.94 to 1.04 at the district level. The VFs for the 20 vaccination clinics ranged from 0.57 to 1.07. The VFs for Shangyu District was 0.98. The mean of total QI score of the 20 vaccination clinics was 80.32%. A significant correlation between the VFs of the 3rd dose of the diphtheria–tetanus–pertussis combined vaccine (DTP) and QI scores was observed at the vaccination clinic level. Conclusions: Deficiencies in data consistency and immunization reporting practice in Shangyu District were observed. Targeted measures are suggested to improve the quality of the immunization reporting system in vaccination clinics with poor data consistency. PMID:27869729

Auditing the Immunization Data Quality from Routine Reports in Shangyu District, East China.

PubMed

Hu, Yu; Zhang, Xinpei; Li, Qian; Chen, Yaping

2016-11-18

Objective: To evaluate the immunization data quality in Shangyu District, East China. Methods: An audit for immunization data for the year 2014 was conducted in 20 vaccination clinics of Shangyu District. The consistency of immunization data was estimated by verification factors (VFs), which was the proportion of vaccine doses reported as being administered that could be verified by written documentation at vaccination clinics. The quality of monitoring systems was evaluated using the quality index (QI). Results: The VFs of 20 vaccine doses ranged from 0.94 to 1.04 at the district level. The VFs for the 20 vaccination clinics ranged from 0.57 to 1.07. The VFs for Shangyu District was 0.98. The mean of total QI score of the 20 vaccination clinics was 80.32%. A significant correlation between the VFs of the 3rd dose of the diphtheria-tetanus-pertussis combined vaccine (DTP) and QI scores was observed at the vaccination clinic level. Conclusions: Deficiencies in data consistency and immunization reporting practice in Shangyu District were observed. Targeted measures are suggested to improve the quality of the immunization reporting system in vaccination clinics with poor data consistency.

Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management

PubMed Central

Comin‐Colet, Josep; de Francisco, Angel; Dignass, Axel; Doehner, Wolfram; S. P. Lam, Carolyn; Macdougall, Iain C.; Rogler, Gerhard; Camaschella, Clara; Kadir, Rezan; Kassebaum, Nicholas J.; Spahn, Donat R.; Taher, Ali T.; Musallam, Khaled M.

2017-01-01

Abstract Iron deficiency, even in the absence of anemia, can be debilitating, and exacerbate any underlying chronic disease, leading to increased morbidity and mortality. Iron deficiency is frequently concomitant with chronic inflammatory disease; however, iron deficiency treatment is often overlooked, partially due to the heterogeneity among clinical practice guidelines. In the absence of consistent guidance across chronic heart failure, chronic kidney disease and inflammatory bowel disease, we provide practical recommendations for iron deficiency to treating physicians: definition, diagnosis, and disease‐specific diagnostic algorithms. These recommendations should facilitate appropriate diagnosis and treatment of iron deficiency to improve quality of life and clinical outcomes. PMID:28612425

Innovative physical therapy practice: a qualitative verification of factors that support diffusion of innovation in outpatient physical therapy practice

PubMed Central

Sabus, Carla; Spake, Ellen

2016-01-01

Background and purpose New ideas, methods, and technologies spread through cultures through typical patterns described by diffusion of innovation (DOI) theory. Professional cultures, including the physical therapy profession, have distinctive features and traditions that determine the adoption of practice innovation. The Consolidated Framework for Implementation Research (CFIR) proposes a framework of innovation implementation specific to health care services. While the CFIR has been applied to medical and nursing practice, it has not been extended to rehabilitation professions. The purpose of this qualitative study was to verify the CFIR factors in outpatient physical therapy practice. Design Through a nomination process of area rehabilitation managers and area directors of clinical education, 2 exemplar, outpatient, privately owned physical therapy clinics were identified as innovation practices. A total of 18 physical therapists (PTs), including 3 owners and a manager, participated in the study. Methods The 2 clinics served as case studies within a qualitative approach of directed content analysis. Data were collected through observation, spontaneous, unstructured questioning, workflow analysis, structured focus group sessions, and artifact analysis including clinical documents. Focus group data were transcribed. All the data were analyzed and coded among 4 investigators. Results Through data analysis and alignment with literature in DOI theory in health care practice, the factors that determine innovation adoption were verified. The phenomena of implementation in PT practice are largely consistent with models of implementation in health care service. Within the outpatient practices studied, patient-centered care and collaborative learning were foundational elements to diffusion of an innovation. Conclusion Innovation in outpatient physical therapy practice can be understood as a social process situated within the culture of the physical therapy professional that follows predictable patterns that strongly align with DOI theory and the CFIR. PMID:29355199

Innovative physical therapy practice: a qualitative verification of factors that support diffusion of innovation in outpatient physical therapy practice.

PubMed

Sabus, Carla; Spake, Ellen

2016-01-01

New ideas, methods, and technologies spread through cultures through typical patterns described by diffusion of innovation (DOI) theory. Professional cultures, including the physical therapy profession, have distinctive features and traditions that determine the adoption of practice innovation. The Consolidated Framework for Implementation Research (CFIR) proposes a framework of innovation implementation specific to health care services. While the CFIR has been applied to medical and nursing practice, it has not been extended to rehabilitation professions. The purpose of this qualitative study was to verify the CFIR factors in outpatient physical therapy practice. Through a nomination process of area rehabilitation managers and area directors of clinical education, 2 exemplar, outpatient, privately owned physical therapy clinics were identified as innovation practices. A total of 18 physical therapists (PTs), including 3 owners and a manager, participated in the study. The 2 clinics served as case studies within a qualitative approach of directed content analysis. Data were collected through observation, spontaneous, unstructured questioning, workflow analysis, structured focus group sessions, and artifact analysis including clinical documents. Focus group data were transcribed. All the data were analyzed and coded among 4 investigators. Through data analysis and alignment with literature in DOI theory in health care practice, the factors that determine innovation adoption were verified. The phenomena of implementation in PT practice are largely consistent with models of implementation in health care service. Within the outpatient practices studied, patient-centered care and collaborative learning were foundational elements to diffusion of an innovation. Innovation in outpatient physical therapy practice can be understood as a social process situated within the culture of the physical therapy professional that follows predictable patterns that strongly align with DOI theory and the CFIR.

Looking forward and back to relapse: implications for research and practice.

PubMed

Connors, G J; Longabaugh, R; Miller, W R

1996-12-01

In this commentary, the three principal investigators of the Relapse Replication and Extension Project (RREP) reflect on clinical and research implications of study findings from the three collaborating sites. A primary purpose of RREP was to study the reliability and validity of a taxonomy of relapse antecedents originally proposed by Marlatt two decades ago. Under the best of research conditions, with extensive training and practice, it was difficult to achieve reliability of coding with the original three-level system, although with only two levels of classification more reasonable albeit variable reliability was found. Modifications may improve the taxonomy's reliability, but RREP data indicate that a more appropriate strategy is to measure possible antecedents of relapse by continuous scales such as those provided by Annis, Heather and Litman. There is reasonably consistent evidence for two common antecedents of relapse: negative emotional states, and positive emotional states in a social context. Antecedents of relapse show only modest consistency within individuals from one occasion to the next. The causes to which clients attribute relapses may exert a significant effect on future drinking episodes. Stable and internal attributions, such as are commonly associated with a dispositional disease model, may serve to perpetuate relapse. From the RREP studies, the availability of coping skills appears to be a potent protective factor, and ineffective coping a consistent predictor of relapse. Implications for clinical research and practice are considered.

Validating an instrument for selecting interventions to change physician practice patterns: a Michigan Consortium for Family Practice Research study.

PubMed

Green, Lee A; Gorenflo, Daniel W; Wyszewianski, Leon

2002-11-01

The goal of this study was to develop a psychometric instrument that classified physiciansamprsquo response styles to new information as seekers, receptives, traditionalists, or pragmatists. This classification was based on specific combinations of 3 scales: (a) belief in evidence vs experience as the basis of knowledge, (b) willingness to diverge from common or previous practice, and (c) sensitivity to pragmatic concerns of practice. The instrument will help focus efforts to change practice more accurately. This was a cross-sectional study of physician responses to a psychometric instrument. Paper-and-pencil survey forms were distributed to 3 waves of physicians, with revision for improved internal consistency at each iteration. Participants were 1393 primary care physicians at continuing education events in the Midwest or at primary care clinic sites in the Veteransamprsquo Health Administration system. Internal consistency was measured by factor analysis with orthogonal rotation and Cronbachamprsquos alpha. A total of 1287 usable instruments were returned (106, 1120, and 61 in the 3 iterations, respectively), representing approximately three fourths of distributed forms. Final scale internal consistencies were a = 0.79, b = 0.74, and c = 0.68. The patterns of scores on the 3 scales were consistent with the predictions of the theoretical scheme of physician types. The "seeker" type was the rarest, at fewer than 3%. It is possible to reliably classify physicians into categories that a theoretical framework predicts will respond differently to different interventions for implementing guidelines and translating research findings into practice. The next step is to demonstrate that the classification predicts physician practice behavior.

Adaptation of clinical prediction models for application in local settings.

PubMed

Kappen, Teus H; Vergouwe, Yvonne; van Klei, Wilton A; van Wolfswinkel, Leo; Kalkman, Cor J; Moons, Karel G M

2012-01-01

When planning to use a validated prediction model in new patients, adequate performance is not guaranteed. For example, changes in clinical practice over time or a different case mix than the original validation population may result in inaccurate risk predictions. To demonstrate how clinical information can direct updating a prediction model and development of a strategy for handling missing predictor values in clinical practice. A previously derived and validated prediction model for postoperative nausea and vomiting was updated using a data set of 1847 patients. The update consisted of 1) changing the definition of an existing predictor, 2) reestimating the regression coefficient of a predictor, and 3) adding a new predictor to the model. The updated model was then validated in a new series of 3822 patients. Furthermore, several imputation models were considered to handle real-time missing values, so that possible missing predictor values could be anticipated during actual model use. Differences in clinical practice between our local population and the original derivation population guided the update strategy of the prediction model. The predictive accuracy of the updated model was better (c statistic, 0.68; calibration slope, 1.0) than the original model (c statistic, 0.62; calibration slope, 0.57). Inclusion of logistical variables in the imputation models, besides observed patient characteristics, contributed to a strategy to deal with missing predictor values at the time of risk calculation. Extensive knowledge of local, clinical processes provides crucial information to guide the process of adapting a prediction model to new clinical practices.

Long-term prospective teaching effectivity of practical skills training and a first OSCE in cranio maxillofacial surgery for dental students.

PubMed

Landes, Constantin A; Hoefer, Sebastian; Schuebel, Florian; Ballon, Alexander; Teiler, Anna; Tran, Andreas; Weber, Roxane; Walcher, Felix; Sader, Robert

2014-07-01

Basic skills in oral/CMF surgery should be taught effectively to dental students as surgical skills training is traditionally under-represented in the dental curriculum compared to its later need in daily clinical practice. Rigid curricular time frames and prospectively condensed professional education foster new effective teaching and examination formats. Transmitting and assessing clinical competence objectively (independent of subjective bias), reliably (repeatable, inter-rater consistency) and valid (representative, structured task selection) was intended and evaluated in oral/CMF surgery skills acquisition starting in summer 2009. A small-group practical skills training (PST) day initiated a one-week practical training course, covering previously formulated learning objectives. An objective structured clinical evaluation (OSCE) was held at the end of each semester. Theoretical background knowledge and clinical skills should have to be memorized within a representative number of practical tasks (test stations). A first semester (26 students) used classical practical training alone as controls, the following semesters (171 students) had PST, considered as a study group. All 197 students were assessed with OSCE's over a 3-year period. An instructor held PST based on presentations, videos and practical training, including mannequins, with pairs of students. This included history taking, communication and interpretation of laboratory/image diagnostics, structured clinical facial examination, fracture diagnosis, venipuncture, suturing, biopsy and wire loops on pig jaws for manual and clinical skills, which were later incorporated in OSCE stations. OSCE average results increased from 63.3 ± 9.7% before and to 75.5 ± 10% after the inclusion of PST (p < 0.05). Knowledge diffusion between sittings on the same test date and between consecutive semesters was insignificant. Students and faculty rated their learning/teaching experience "very good" to "good". PST was effective in optimizing clinical skills as evaluated by OSCE. Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

SU-E-E-05: Improving Contouring Precision and Consistency for Physicians-In-Training with Simple Lab Experiments

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ma, L; Larson, D A

2015-06-15

Purpose: Target contouring for high-dose treatments such as radiosurgery of brain metastases is highly critical in eliminating marginal failure and reducing complications as shown by recent clinical studies. In order to improve contouring accuracy and practice consistency for the procedure, we introduced a self-assessed physics lab practice for the physicians-in-training. Methods: A set of commercially acquired high-precision PMMA plastic spheres were randomly embedded in a Styrofoam block and then scanned with the CT/MR via the clinical procedural imaging protocol. A group of first-year physicians-in-training (n=6) from either neurosurgery or radiation oncology department were asked to contour the scanned objects (diametermore » ranged from 0.4 cm to 3.8 cm). These user-defined contours were then compared with the ideal contour sets of object shape for self assessments to determine the maximum areas of the observed discrepancies and method of improvements. Results: The largest discrepancies from initial practice were consistently found to be located near the extreme longitudinal portions of the target for all the residents. Discrepancy was especially prominent when contouring small objects < 1.0 cm in diameters. For example, the mean volumes rendered from the initial contour data set differed from the ideal data set by 7.7%±6.6% for the participants (p> 0.23 suggesting agreement cannot be established). However, when incorporating a secondary imaging scan such as reconstructed coronal or sagittal images in a repeat practice, the agreement was dramatically improved yielding p<0.02 in agreement with the reference data set for all the participants. Conclusion: A simple physics lab revealed a common pitfall in contouring small metastatic brain tumors for radiosurgical procedures and provided a systematic tool for physicians-in-training in improving their clinical contouring skills. Dr Ma is current a board member of international stereotactic radiosurgical society.« less

Exploring the relationship between client perspectives, clinical expertise and research evidence.

PubMed

Roulstone, Sue

2015-06-01

This paper examines the relationship between components of evidence-based practice (clinical expertise, patient perspective and research evidence). Findings are examined from two research programs: the Better Communication Research Program and Child Talk, including exploratory studies of the views of parents and children regarding speech-language pathology and studies of current practice by SLPs in England. Systematic reviews of the research literature were also undertaken. The paper analyses relationships between outcomes valued by children and parents and those reported in the literature and in practice, parents' perspectives regarding intervention in comparison with clinicians' reports of practice and the extent to which research evidence underpins current practice is examined. Parents and children value functional outcomes and positive experiences; these are not routinely measured in research or practice. Therapy is perceived positively by most parents; however, some are ambivalent and less clear about the rationale. Commonly used interventions are supported by evidence, but there are gaps regarding some critical therapy components. The paper discusses four challenges to evidence-based practice: the consistency and clarity of descriptions of interventions; consensus based models of practice; understanding of the mechanisms of change; and, finally, the operationalization of client preferences within an evidence-based practice framework.

Cross-disciplinary research in cancer: an opportunity to narrow the knowledge-practice gap.

PubMed

Urquhart, R; Grunfeld, E; Jackson, L; Sargeant, J; Porter, G A

2013-12-01

Health services researchers have consistently identified a gap between what is identified as "best practice" and what actually happens in clinical care. Despite nearly two decades of a growing evidence-based practice movement, narrowing the knowledge-practice gap continues to be a slow, complex, and poorly understood process. Here, we contend that cross-disciplinary research is increasingly relevant and important to reducing that gap, particularly research that encompasses the notion of transdisciplinarity, wherein multiple academic disciplines and non-academic individuals and groups are integrated into the research process. The assimilation of diverse perspectives, research approaches, and types of knowledge is potentially effective in helping research teams tackle real-world patient care issues, create more practice-based evidence, and translate the results to clinical and community care settings. The goals of this paper are to present and discuss cross-disciplinary approaches to health research and to provide two examples of how engaging in such research may optimize the use of research in cancer care.

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory.

PubMed

Kuiper, Ruth Anne; Pesut, Daniel J

2004-02-01

Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills. While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development. Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts. This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills. Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases. The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking. Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition. This skill acquisition is best accomplished through teaching-learning attention to self-regulation learning theory. A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory. It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development. Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development. While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts. Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies. The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts.

Patients' Characteristics Affecting Physician-Patient Nonverbal Communication.

ERIC Educational Resources Information Center

Street, Richard L.; Buller, David B.

1988-01-01

Examines the impact of patients' characteristics on patterns of nonverbal communication exhibited in physician-patient interactions at a family practice clinic. Finds some general patterns of nonverbal behavioral differences, consistency, and adaptation characterizing the entire data set, and that patients' characteristics influenced patterns of…

Screening and assessment of chronic pain among children with cerebral palsy: a process evaluation of a pain toolbox.

PubMed

Orava, Taryn; Provvidenza, Christine; Townley, Ashleigh; Kingsnorth, Shauna

2018-06-08

Though high numbers of children with cerebral palsy experience chronic pain, it remains under-recognized. This paper describes an evaluation of implementation supports and adoption of the Chronic Pain Assessment Toolbox for Children with Disabilities (the Toolbox) to enhance pain screening and assessment practices within a pediatric rehabilitation and complex continuing care hospital. A multicomponent knowledge translation strategy facilitated Toolbox adoption, inclusive of a clinical practice guideline, cerebral palsy practice points and assessment tools. Across the hospital, seven ambulatory care clinics with cerebral palsy caseloads participated in a staggered roll-out (Group 1: exclusive CP caseloads, March-December; Group 2: mixed diagnostic caseloads, August-December). Evaluation measures included client electronic medical record audit, document review and healthcare provider survey and interviews. A significant change in documentation of pain screening and assessment practice from pre-Toolbox (<2%) to post-Toolbox adoption (53%) was found. Uptake in Group 2 clinics lagged behind Group 1. Opportunities to use the Toolbox consistently (based on diagnostic caseload) and frequently (based on client appointments) were noted among contextual factors identified. Overall, the Toolbox was positively received and clinically useful. Findings affirm that the Toolbox, in conjunction with the application of integrated knowledge translation principles and an established knowledge translation framework, has potential to be a useful resource to enrich and standardize chronic pain screening and assessment practices among children with cerebral palsy. Implications for Rehabilitation It is important to engage healthcare providers in the conceptualization, development, implementation and evaluation of a knowledge-to-action best practice product. The Chronic Pain Toolbox for Children with Disabilities provides rehabilitation staff with guidance on pain screening and assessment best practice and offers a range of validated tools that can be incorporated in ambulatory clinic settings to meet varied client needs. Considering unique clinical contexts (i.e., opportunities for use, provider engagement, staffing absences/turnover) is required to optimize and sustain chronic pain screening and assessment practices in rehabilitation outpatient settings.

Academic training and clinical placement problems to achieve nursing competency

PubMed Central

RAHMATI SHARGHI, NARJES; ALAMI, ALI; KHOSRAVAN, SHAHLA; MANSOORIAN, MOHAMMAD REZA; EKRAMI, ALI

2015-01-01

Introduction: High quality of care is one of the requirements of nursing which depends on the nursing competency. In this connection, the aim of this research was to determine the problems related to the academic training (nursing' educational program) and clinical practice to achieve competency from the viewpoint of nurses, faculty members, and nursing students. Methods: the study was an analytical cross-sectional one. The sample consisted of the academic staff, the third and the fourth year nursing students and nurses in practice. The instrument of the study was a two-part researcher-made questionnaire with 22 questions in the theoretical- clinical realm to assess  problems related to the theoretical and clinical teaching in nursing, and 23 questions to assess the clinical functions. The questionnaire was validated in terms of both face and content validity. Its reliability, using Cronbach's Alpha coefficient, was 0.72 in the theoretical-clinical and 0.73 in the clinical realm. Both descriptive and analytical statistics were used to analyze the data, using SPSS software. Results: The results of this study indicated that from the participants’ viewpoints, the most important problems in the academic education for nursea to acquire competency were as follows: lack of academic research the clinical period (88.9%), no application of theoretical aspects of the nursing process in practice (85.6%), insufficient knowledgeable and professional educators (81.1%), the use of traditional routine-oriented methods on the wards (75.6%); also insufficient time for performance based on knowledge in relation to  the nurse's workload (86.5%), weakness and usefulness of scientific function encouragement systems in clinic (85.2%), and learnt theoretical subjects not coming into practice in clinical fields after graduation (75.6%). Conclusion: Efforts to reduce the gap between the theoretical and practical (clinical function) knowledge in educational and work environment are required to improve the training of qualified nurses. PMID:25587550

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma.

PubMed

Wall, Christopher J; Lynch, Joan; Harris, Ian A; Richardson, Martin D; Brand, Caroline; Lowe, Adrian J; Sugrue, Michael

2010-03-01

Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well-designed clinical trial evidence. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.

Bridging the gap between the neurocognitive lab and the addiction clinic.

PubMed

Franken, Ingmar H A; van de Wetering, Ben J M

2015-05-01

In the past decennium there has been an enormous increase in new insights in cognitive mechanisms of addiction and their neural substrates. These candidate neurocognitive mechanisms, particularly those associated with "drive" and "control" aspects of addiction, are clearly involved in substance use problems but do not yet provide a full explanation. The neurocognitive mechanisms addressed in the present perspective are attentional bias, reward processing (both drive aspects) and error-processing and cognitive control (both control aspects). The time has come to transfer these recent insights more consistently to clinical practice by studying their relevance for diagnosis and treatment in patient samples. The present perspective echoes the development of recent initiatives such as the RDoC system to integrate developments in neuroscience into clinical practice. The aim of this article is to open new vistas for addiction diagnosis and treatment and to discuss why and how these neurocognitive aspects of addictive behavior can be used in clinical practice. In addition, present problematic issues and a future research agenda are provided. Copyright © 2014 Elsevier Ltd. All rights reserved.

Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students.

PubMed

Briggs, A M; Slater, H; Smith, A J; Parkin-Smith, G F; Watkins, K; Chua, J

2013-05-01

Evidence points to clinicians' beliefs and practice behaviours related to low back pain (LBP), which are discordant with contemporary evidence. While interventions to align beliefs and behaviours with evidence among clinicians have demonstrated effectiveness, a more sustainable and cost-effective approach to positively developing workforce capacity in this area may be to target the emerging workforce. The aim of this study was to investigate beliefs and clinical recommendations for LBP, and their alignment to evidence, in Australian university allied health and medical students. Final-year students in chiropractic, medicine, occupational therapy, pharmacy and physiotherapy disciplines in three Western Australian universities responded to a survey. Demographic data, LBP-related beliefs data [modified Health Care Providers Pain and Impact Relationship Scale (HC-PAIRS) and the Back Pain Beliefs Questionnaire (BBQ)] and activity, rest and work clinical recommendations for an acute LBP clinical vignette were collected. Six hundred two students completed the survey (response rate 74.6%). Cross-discipline differences in beliefs and clinical recommendations were observed (p > 0.001). Physiotherapy and chiropractic students reported significantly more helpful beliefs compared with the other disciplines, while pharmacy students reported the least helpful beliefs. A greater proportion of chiropractic and physiotherapy students reported guideline-consistent recommendations compared with other disciplines. HC-PAIRS and BBQ scores were strongly associated with clinical recommendations, independent to the discipline of study and prior experience of LBP. Aligning cross-discipline university curricula with current evidence may provide an opportunity to facilitate translation of this evidence into practice with a focus on a consistent, cross-discipline approach to LBP management. © 2012 European Federation of International Association for the Study of Pain Chapters.

Establishing cross-discipline consensus on contraception, pregnancy and breast feeding-related educational messages and clinical practices to support women with rheumatoid arthritis: an Australian Delphi study

PubMed Central

Jordan, Joanne E; Ackerman, Ilana N; Van Doornum, Sharon

2016-01-01

Objective Recognising the need for a best-practice and consistent approach in providing care to women with rheumatoid arthritis (RA) in relation to (1) general health, (2) contraception, (3) conception and pregnancy, (4) breast feeding and (5) early parenting, we sought to achieve cross-discipline, clinical consensus on key messages and clinical practice behaviours in these 5 areas. Design 3-round eDelphi study. In round 1, panellists provided free-text responses to open-ended questions about care for women with RA across the 5 areas. Subsequently, panellists refined and scored the synthesised responses, presented as metathemes, themes and detailed elements. Where ≥5% of panellists did not support a theme in a given round, it was removed. Setting Panel of practicing Australian rheumatologists (n=22), obstetricians/obstetric medicine physicians (n=9) and pharmacists (n=5). Results 34 (94.4%) panellists participated in all 3 rounds. The panel supported 18 themes across the 5 areas (support/strongly support: 88.2–100%) underpinned by 5 metathemes. Metathemes focused on coordination in information delivery, the mode and timing of information delivery, evidence underpinning information, engagement of the right health professionals at the right time and a non-judgemental approach to infant feeding. Themes included practices for primary prevention of chronic disease and their sequelae, the importance of contraception and planning pregnancy and breast feeding, close monitoring of medications, supporting mental well-being, managing disease activity and providing practical support for early parenting. Conclusions A cross-disciplinary clinical panel highly supported key information and clinical practices in the care for women with RA across the continuum of contraception to early parenting within a whole-person, chronic disease management approach. PMID:27633637

The Association of Shelter Veterinarians' 2016 Veterinary Medical Care Guidelines for Spay-Neuter Programs.

PubMed

Griffin, Brenda; Bushby, Philip A; McCobb, Emily; White, Sara C; Rigdon-Brestle, Y Karla; Appel, Leslie D; Makolinski, Kathleen V; Wilford, Christine L; Bohling, Mark W; Eddlestone, Susan M; Farrell, Kelly A; Ferguson, Nancy; Harrison, Kelly; Howe, Lisa M; Isaza, Natalie M; Levy, Julie K; Looney, Andrea; Moyer, Michael R; Robertson, Sheilah Ann; Tyson, Kathy

2016-07-15

As community efforts to reduce the overpopulation and euthanasia of unwanted and unowned cats and dogs have increased, many veterinarians have increasingly focused their clinical efforts on the provision of spay-neuter services. Because of the wide range of geographic and demographic needs, a wide variety of spay-neuter programs have been developed to increase delivery of services to targeted populations of animals, including stationary and mobile clinics, MASH-style operations, shelter services, community cat programs, and services provided through private practitioners. In an effort to promote consistent, high-quality care across the broad range of these programs, the Association of Shelter Veterinarians convened a task force of veterinarians to develop veterinary medical care guidelines for spay-neuter programs. These guidelines consist of recommendations for general patient care and clinical procedures, preoperative care, anesthetic management, surgical procedures, postoperative care, and operations management. They were based on current principles of anesthesiology, critical care medicine, infection control, and surgical practice, as determined from published evidence and expert opinion. They represent acceptable practices that are attainable in spay-neuter programs regardless of location, facility, or type of program. The Association of Shelter Veterinarians envisions that these guidelines will be used by the profession to maintain consistent veterinary medical care in all settings where spay-neuter services are provided and to promote these services as a means of reducing sheltering and euthanasia of cats and dogs.

A Clinical Nurse Leader (CNL) practice development model to support integration of the CNL role into microsystem care delivery.

PubMed

Kaack, Lorraine; Bender, Miriam; Finch, Michael; Borns, Linda; Grasham, Katherine; Avolio, Alice; Clausen, Shawna; Terese, Nadine A; Johnstone, Diane; Williams, Marjory

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.'s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.'s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery. Published by Elsevier Inc.

Wisconsin health practice rebrands image with "life has its moments" campaign.

PubMed

2007-01-01

Wisconsin's largest healthcare system has 41 clinics throughout the state and offers a variety of services, from women's health to oncology. Maintaining a consistent brand message in a large organization with so many product lines requires constant marketing to ensure consumer awareness. To that end, Marshfield Clinic recently launched an effort to revitalize its brand and spread its message, through television spots, print ads, and billboards.

The m-Health revolution: Exploring perceived benefits of WhatsApp use in clinical practice.

PubMed

Ganasegeran, Kurubaran; Renganathan, Pukunan; Rashid, Abdul; Al-Dubai, Sami Abdo Radman

2017-01-01

The dawn of m-Health facilitates new horizons of professional communication through WhatsApp, allowing health professionals to interact fast and efficiently for effective patient management. This preliminary study aimed to investigate perceived benefits, if any, of WhatsApp use across general medical and emergency teams during clinical practice in Malaysia. A cross-sectional study was conducted in a universal sample of 307 health professionals comprising of nurses, medical assistants, medical residents, medical officers and physicians across medical and casualty departments in a Malaysian public hospital. The self-administered questionnaire consisted of items on socio-demographics, WhatsApp usage characteristics and the type of communication events during clinical practice. The majority of respondents (68.4%) perceived WhatsApp as beneficial during clinical practice. In multivariate analysis, perceived benefits was significantly higher amongst the clinical management group (aOR=2.6, 95% CI 1.5-4.6, p=0.001), those using WhatsApp for >12months (aOR=1.7, 95% CI 1.0-3.0, p=0.047), those receiving response ≤15min to a new communication (aOR=1.9, 95% CI 1.1-3.2, p=0.017), and frequent information giving events (aOR=2.4, 95% CI 1.2-4.8, p=0.016). Perceived benefits of WhatsApp use in clinical practice was significantly associated with usage characteristics and type of communication events. This study lays the foundation for quality improvement innovations in patient management delivered through m-Health technology. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Computerized clinical decision support for prescribing: provision does not guarantee uptake

PubMed Central

Moxey, Annette; Robertson, Jane; Newby, David; Hains, Isla; Williamson, Margaret; Pearson, Sallie-Anne

2010-01-01

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990–2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved. PMID:20064798

Measuring standing balance in multiple sclerosis: Further progress towards an automatic and reliable method in clinical practice.

PubMed

Keune, Philipp M; Young, William R; Paraskevopoulos, Ioannis T; Hansen, Sascha; Muenssinger, Jana; Oschmann, Patrick; Müller, Roy

2017-08-15

Balance deficits in multiple sclerosis (MS) are often monitored by means of observer-rated tests. These may provide reliable data, but may also be time-consuming, subject to inter-rater variability, and potentially insensitive to mild fluctuations throughout the clinical course. On the other hand, laboratory assessments are often not available. The Nintendo Wii Balance Board (WBB) may represent a low-cost solution. The purpose of the current study was to examine the methodological quality of WBB data in MS (internal consistency, test-retest reliability), convergent validity with observer-rated tests (Berg Balance Scale, BBS; Timed-Up and Go Test, TUG), and discriminative validity concerning clinical status (Expanded Disability Status Scale, EDSS). Standing balance was assessed with the WBB for 4min in 63 MS patients at two assessment points, four months apart. Additionally, patients were examined with the BBS, TUG and the EDSS. A period of 4min on the WBB provided data characterized by excellent internal consistency and test-retest reliability. Significant correlations between WBB data and results of the BBS and TUG were obtained after merely 2min on the board. An EDSS median-split revealed that higher EDSS values (>3) were associated with significantly increased postural sway on the WBB. WBB measures reflecting postural sway are methodologically robust in MS, involving excellent internal consistency and test-retest reliability. They are also characterized by convergent validity with other considerably lengthier observer-rated balance measures (BBS) and sensitive to broader clinical characteristics (EDSS). The WBB may hence represent an effective, easy-to-use monitoring tool for MS patients in clinical practice. Copyright © 2017 Elsevier B.V. All rights reserved.

How are evidence and knowledge used in orthopaedic decision-making? Three comparative case studies of different approaches to implementation of clinical guidance in practice.

PubMed

Grove, Amy; Clarke, Aileen; Currie, Graeme

2018-05-31

The uptake and use of clinical guidelines is often insufficient to change clinical behaviour and reduce variation in practice. As a consequence of diverse organisational contexts, the simple provision of guidelines cannot ensure fidelity or guarantee their use when making decisions. Implementation research in surgery has focused on understanding what evidence exists for clinical practice decisions but limits understanding to the technical, educational and accessibility issues. This research aims to identify where, when and how evidence and knowledge are used in orthopaedic decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice. We used in-depth case studies to examine guideline implementation in real-life surgical practice. We conducted comparative case studies in three English National Health Service hospitals over a 12-month period. Each in-depth case study consisted of a mix of qualitative methods including interviews, observations and document analysis. Data included field notes from observations of day-to-day practice, 64 interviews with NHS surgeons and staff and the collection of 121 supplementary documents. Case studies identified 17 sources of knowledge and evidence which influenced clinical decisions in elective orthopaedic surgery. A comparative analysis across cases revealed that each hospital had distinct approaches to decision-making. Decision-making is described as occurring as a result of how 17 types of knowledge and evidence were privileged and of how they interacted and changed in context. Guideline implementation was contingent and mediated through four distinct contextual levels. Implementation could be assessed for individual surgeons, groups of surgeons or the organisation as a whole, but it could also differ between these levels. Differences in how evidence and knowledge were used contributed to variations in practice from guidelines. A range of complex and competing sources of evidence and knowledge exists which influence the working practices of healthcare professionals. The dynamic selection, combination and use of each type of knowledge and evidence influence the implementation and use of clinical guidance in practice. Clinical guidelines are a fundamental part of practice, but represent only one type of evidence influencing clinical decisions. In the orthopaedic speciality, other distinct sources of evidence and knowledge are selected and used which impact on how guidelines are implemented. New approaches to guideline implementation need to appreciate and incorporate this diverse range of knowledge and evidence which influences clinical decisions and to take account of the changing contexts in which decisions are made.

Leaving behind our preparadigmatic past: Professional psychology as a unified clinical science.

PubMed

Melchert, Timothy P

2016-09-01

The behavioral and neurosciences have made remarkable progress recently in advancing the scientific understanding of human psychology. Though research in many areas is still in its early stages, knowledge of many psychological processes is now firmly grounded in experimental tests of falsifiable theories and supports a unified, paradigmatic understanding of human psychology that is thoroughly consistent with the rest of the natural sciences. This new body of knowledge poses critical questions for professional psychology, which still often relies on the traditional theoretical orientations and other preparadigmatic practices for guiding important aspects of clinical education and practice. This article argues that professional psychology needs to systematically transition to theoretical frameworks and a curriculum that are based on an integrated scientific understanding of human psychology. Doing so would be of historic importance for the field and would result in major changes to professional psychology education and practice. It would also allow the field to emerge as a true clinical science. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Doctors' experience with handheld computers in clinical practice: qualitative study.

PubMed

McAlearney, Ann Scheck; Schweikhart, Sharon B; Medow, Mitchell A

2004-05-15

To examine doctors' perspectives about their experiences with handheld computers in clinical practice. Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns. Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists. 54 doctors who did or did not use handheld computers. Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking. Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care.

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment.

PubMed

Marcus, Brian S; Carlson, Jestin N; Hegde, Gajanan G; Shang, Jennifer; Venkat, Arvind

2016-03-01

We sought to evaluate whether health care professionals' viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108-tertiary care center, 92-large community hospitals, 40-small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.

Analysis of Existing Guidelines for the Systematic Planning Process of Clinical Registries.

PubMed

Löpprich, Martin; Knaup, Petra

2016-01-01

Clinical registries are a powerful method to observe the clinical practice and natural disease history. In contrast to clinical trials, where guidelines and standardized methods exist and are mandatory, only a few initiatives have published methodological guidelines for clinical registries. The objective of this paper was to review these guidelines and systematically assess their completeness, usability and feasibility according to a SWOT analysis. The results show that each guideline has its own strengths and weaknesses. While one supports the systematic planning process, the other discusses clinical registries in great detail. However, the feasibility was mostly limited and the special requirements of clinical registries, their flexible, expandable and adaptable technological structure was not addressed consistently.

Factors associated with clinical inertia: an integrative review

PubMed Central

Aujoulat, Isabelle; Jacquemin, Patricia; Rietzschel, Ernst; Scheen, André; Tréfois, Patrick; Wens, Johan; Darras, Elisabeth; Hermans, Michel P

2014-01-01

Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia. PMID:24868181

Development of a university-based emergency department network: lessons learned.

PubMed

Pimentel, Laura; Hirshon, Jon Mark; Barrueto, Fermin; Browne, Brian J

2012-10-01

As part of the growth of emergency medical care in our state, our university-based emergency medicine practice developed a network of affiliated emergency department (ED) practices. The original practices were academic and based on a faculty practice model; more recent network development incorporated a community practice model less focused on academics. This article discusses the growth of that network, with a focus on the recent addition of a county-wide two-hospital emergency medicine practice. During the transition of the two EDs from a contract management group to the university network, six critical areas in need of restructuring were identified: 1) departmental leadership, 2) recruitment and retention of clinical staff members, 3) staffing strategies, 4) relationships with key constituents, 5) clinical operations, supplies, and equipment, and 6) compensation structure. The impact of changes was measured by comparison of core measures, efficiency metrics, patient volumes, admissions, and transfers to the academic medical center before and after the implementation of our practice model. Our review and modification of these components significantly improved the quality and efficiency of care at the community hospital system. The consistent presence of board certified emergency physicians optimized utilization of clinical resources in the community hospital and the academic health system. This dynamic led to a mutually beneficial merger of these major state healthcare systems. Copyright © 2012 Elsevier Inc. All rights reserved.

A Novel Approach to Improving Utilization of Laboratory Testing.

PubMed

Zhou, Yaolin; Procop, Gary W; Riley, Jacquelyn D

2018-02-01

- The incorporation of best practice guidelines into one's institution is a challenging goal of utilization management, and the successful adoption of such guidelines depends on institutional context. Laboratorians who have access to key clinical data are well positioned to understand existing local practices and promote more appropriate laboratory testing. - To apply a novel approach to utilization management by reviewing international clinical guidelines and current institutional practices to create a reliable mechanism to improve detection and reduce unnecessary tests in our patient population. - We targeted a frequently ordered genetic test for HFE-related hereditary hemochromatosis, a disorder of low penetrance. After reviewing international practice guidelines, we evaluated 918 HFE tests and found that all patients with new diagnoses had transferrin saturation levels that were significantly higher than those of patients with nonrisk genotypes (72% versus 42%; P < .001). - Our "one-button" order that restricts HFE genetic tests to patients with transferrin saturation greater than 45% is consistent with published practice guidelines and detected 100% of new patients with HFE-related hereditary hemochromatosis. - Our proposed algorithm differs from previously published approaches in that it incorporates both clinical practice guidelines and local physician practices, yet requires no additional hands-on effort from pathologists or clinicians. This novel approach to utilization management embraces the role of pathologists as leaders in promoting high-quality patient care in local health care systems.

Justification of radiographic examinations: What are the key issues?

PubMed

Vom, Jason; Williams, Imelda

2017-09-01

Justification of radiographic examinations is the practice of evaluating requested radiological examinations to assess for clinical merit and appropriateness based on clinical notes and patient information. This implies that justification in radiography requires the evaluation of requested examinations, the justification of exposures being applied and determining whether patients fit the recommended criteria for the procedure. Medico-legal requirements by the professional registration body, the Medical Radiation Practice Board of Australia (MRPBA), identify justification as an advocated and obligatory practice for radiographers. Yet, justification remains an inconsistent practice implemented amongst Australian radiographers. This review aims to identify associated barriers inhibiting the consistent practice of justification and the hesitance by radiographers in practicing justification responsibilities. It also recommends a change in workplace culture which encourages radiographers to accept a more autonomous role that cultivates critical thinking, reflection and research-informed decision making as justification will ultimately benefit patients. © 2017 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.

Implementing community-based provider participation in research: an empirical study.

PubMed

Teal, Randall; Bergmire, Dawn M; Johnston, Matthew; Weiner, Bryan J

2012-05-08

Since 2003, the United States National Institutes of Health (NIH) has sought to restructure the clinical research enterprise in the United States by promoting collaborative research partnerships between academically-based investigators and community-based physicians. By increasing community-based provider participation in research (CBPPR), the NIH seeks to advance the science of discovery by conducting research in clinical settings where most people get their care, and accelerate the translation of research results into everyday clinical practice. Although CBPPR is seen as a promising strategy for promoting the use of evidence-based clinical services in community practice settings, few empirical studies have examined the organizational factors that facilitate or hinder the implementation of CBPPR. The purpose of this study is to explore the organizational start-up and early implementation of CBPPR in community-based practice. We used longitudinal, case study research methods and an organizational model of innovation implementation to theoretically guide our study. Our sample consisted of three community practice settings that recently joined the National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP) in the United States. Data were gathered through site visits, telephone interviews, and archival documents from January 2008 to May 2011. The organizational model for innovation implementation was useful in identifying and investigating the organizational factors influencing start-up and early implementation of CBPPR in CCOP organizations. In general, the three CCOP organizations varied in the extent to which they achieved consistency in CBPPR over time and across physicians. All three CCOP organizations demonstrated mixed levels of organizational readiness for change. Hospital management support and resource availability were limited across CCOP organizations early on, although they improved in one CCOP organization. As a result of weak IPPs, all three CCOPs created a weak implementation climate. Patient accrual became concentrated over time among those groups of physicians for whom CBPPR exhibited a strong innovation-values fit. Several external factors influenced innovation use, complicating and enriching our intra-organizational model of innovation implementation. Our results contribute to the limited body of research on the implementation of CBPPR. They inform policy discussions about increasing and sustaining community clinician involvement in clinical research and expand on theory about organizational determinants of implementation effectiveness.

Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines.

PubMed

Klein, David A; Malcolm, Nikita M; Berry-Bibee, Erin N; Paradise, Scott L; Coulter, Jessica S; Keglovitz Baker, Kristin; Schvey, Natasha A; Rollison, Julia M; Frederiksen, Brittni N

2018-04-01

LGBT clients have unique healthcare needs but experience a wide range of quality in the care that they receive. This study provides a summary of clinical guideline recommendations related to the provision of primary care and family planning services for LGBT clients. In addition, we identify gaps in current guidelines, and inform future recommendations and guidance for clinical practice and research. PubMed, Cochrane, and Agency for Healthcare Research and Quality electronic bibliographic databases, and relevant professional organizations' websites, were searched to identify clinical guidelines related to the provision of primary care and family planning services for LGBT clients. Information obtained from a technical expert panel was used to inform the review. Clinical guidelines meeting the inclusion criteria were assessed to determine their alignment with Institute of Medicine (IOM) standards for the development of clinical practice guidelines and content relevant to the identified themes. The search parameters identified 2,006 clinical practice guidelines. Seventeen clinical guidelines met the inclusion criteria. Two of the guidelines met all eight IOM criteria. However, many recommendations were consistent regarding provision of services to LGBT clients within the following themes: clinic environment, provider cultural sensitivity and awareness, communication, confidentiality, coordination of care, general clinical principles, mental health considerations, and reproductive health. Guidelines for the primary and family planning care of LGBT clients are evolving. The themes identified in this review may guide professional organizations during guideline development, clinicians when providing care, and researchers conducting LGBT-related studies.

Development and psychometric testing of the Clinical Learning Organisational Culture Survey (CLOCS).

PubMed

Henderson, Amanda; Creedy, Debra; Boorman, Rhonda; Cooke, Marie; Walker, Rachel

2010-10-01

This paper describes the development and psychometric testing of the Clinical Learning Organisational Culture Survey (CLOCS) that measures prevailing beliefs and assumptions important for learning to occur in the workplace. Items from a tool that measured motivation in workplace learning were adapted to the nursing practice context. The tool was tested in the clinical setting, and then further modified to enhance face and content validity. Registered nurses (329) across three major Australian health facilities were surveyed between June 2007 and September 2007. An exploratory factor analysis identified five concepts--recognition, dissatisfaction, affiliation, accomplishment, and influence. VALIDITY AND RELIABILITY: Internal consistency measures of reliability revealed that four concepts had good internal consistency: recognition (alpha=.914), dissatisfaction (alpha=.771), affiliation (alpha=.801), accomplishment (alpha=.664), but less so for influence (alpha=.529). This tool effectively measures recognition, affiliation and accomplishment--three concepts important for learning in practice situations, as well as dissatisfied staff across all these domains. Testing of additional influence items identify that this concept is difficult to delineate. The CLOCS can effectively inform leaders about concepts inherent in the culture important for maximising learning by staff. Crown Copyright © 2009. Published by Elsevier Ltd. All rights reserved.

Advanced Critical Care Practitioners - Practical experience of implementing the Advanced Critical Care Practitioner Faculty of Intensive Care Medicine Curriculum in a London Critical Care Unit.

PubMed

Lee, Geraldine; Gilroy, Jo-Anne; Ritchie, Alistair; Grover, Vimal; Gull, Keetje; Gruber, Pascale

2018-05-01

With a chronic shortage of doctors in intensive care, alternative roles are being explored. One of these is the role of the Advanced Critical Care Practitioner. The Advanced Critical Care Practitioner Curriculum was developed by the Faculty of Intensive Care Medicine and is used to provide a structured programme of training. The Advanced Critical Care Practitioner programme consists of an academic and clinical component. This article outlines a practical approach of how the programme was developed and is currently being delivered at a single institution. This new advanced practice role offers opportunities to fill gaps in the medical workforce, improve continuity of patient care, provide mentoring and training for less experienced staff as well as offering a rewarding clinical role.

Enhancing the strategic management of practice learning through the introduction of the role of Learning Environment Manager.

PubMed

Congdon, Graham; Baker, Tracey; Cheesman, Amanda

2013-03-01

This paper describes a process evaluation project designed to enhance the strategic management of practice learning within a large Hospital in the North of England. The aim of the project was to introduce the role of the Learning Environment Manager with dedicated responsibility for practice learning of undergraduate student nurses within the Hospital's 49 practice-settings. Whilst aspects of this role were already evident in several of these settings, the project sought to locate and standardise responsibilities related to the organisation and management of learning and teaching in practice explicitly within the existing staffing structure of each practice-setting. Focus group interviews were used to explore significant aspects of the project with key stakeholder groups comprising Learning Environment Managers, the Hospital Clinical Educator, Hospital Department Managers, Ward Managers, Mentors, University Link Lecturers and undergraduate Student Nurses. Interview data were analysed using thematic content analysis. The findings of the project suggest that the Learning Environment Manager role affords providers of practice learning with a robust approach to establish organisation-wide benchmarks that standardise the strategic management of practice learning in collaboration with partner Universities. The role incorporated many operational activities previously undertaken by the Hospital Clinical Educator, thus enabling the Hospital Clinical Educator to make a more strategic contribution to the on-going quality monitoring and enhancement of practice learning across the Hospital. The Learning Environment Manager role was found to provide mentors with high levels of support which in turn helped to promote consistent, positive and holistic practice learning experiences for undergraduate student nurses across the Hospital. Importantly, the role offers a potent catalyst for nurses in practice to regain responsibility for practice learning and re-establish the value of practice teaching. Copyright © 2012 Elsevier Ltd. All rights reserved.

Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home

PubMed Central

Arar, Nedal H.; Noel, Polly H.; Leykum, Luci; Zeber, John E.; Romero, Raquel; Parchman, Michael L.

2012-01-01

Background Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice. Methods Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed. Results Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy. Practice Implications Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts. PMID:22186171

Forming a Learning Culture to Promote Fracture Prevention Activities

ERIC Educational Resources Information Center

Hjalmarson, Helene V.; Strandmark, Margaretha

2012-01-01

Purpose: The purpose of this paper is to explore interprofessional experiences of incorporating fracture prevention activities in clinical practice inspired by an empowerment approach. Design/methodology/approach: Data collection consisted primarily of focus groups interviews, systematized and analyzed by the grounded theory method. The study took…

Health promotion practice and its implementation in Swedish health care.

PubMed

Brobeck, E; Odencrants, S; Bergh, H; Hildingh, C

2013-09-01

Health promotion practice is an important work assignment within the entire health and medical care sector. Nurses are important for the development and implementation of health promotion in clinical practice. The aim was to describe how district nurses view health promotion practice and how it was implemented in clinical practice following a training initiative. The study has a descriptive design and a qualitative method. The sample consisted of three focus groups with 16 participants. The interviews were conducted as a conversation with focus on the district nurses view of health promotion and its implementation in clinical practice. The data have been processed using manifest qualitative content analysis. Three categories, titled Training as motivation, Lack of grounding and Lack of scope were identified. The result demonstrated that training provides motivation, but also the importance of grounding in the organization and the need for scope in performing health promotion practice. Our results show that the training initiative has contributed positively to the district nurses' view of health promotion practice, but that they also feel that there are obstacles. The district nurses in our study suggest that health promotion practice should be more visible, and not something that is done when time permits. The district nurses feel motivated and have an enthusiasm for health promotion practice but more time and resources are required to design successful health-promoting initiatives. Before implementing a major training initiative for healthcare personnel in health promotion, it is essential to examine whether the conditions for this exist in the organization. © 2013 International Council of Nurses.

The European Society for Medical Oncology Magnitude of Clinical Benefit Scale in daily practice: a single institution, real-life experience at the Medical University of Vienna.

PubMed

Kiesewetter, Barbara; Raderer, Markus; Steger, Günther G; Bartsch, Rupert; Pirker, Robert; Zöchbauer-Müller, Sabine; Prager, Gerald; Krainer, Michael; Preusser, Matthias; Schmidinger, Manuela; Zielinski, Christoph C

2016-01-01

The European Society for Medical Oncology (ESMO) Magnitude of Clinical Benefit Scale (MCBS) has been designed to stratify the therapeutic benefit of a certain drug registered for the treatment of cancer. However, though internally validated, this tool has not yet been evaluated for its feasibility in the daily practice of a major center of medical oncology. The practicability of the MCBS for advanced oncological diseases at the Clinical Division of Oncology, Medical University of Vienna, which constitutes one of the largest oncological centres in Europe, was analysed in a three-step approach. First, retrospectively collected data were analysed to gain an overview of treatments in regular use. Second, data were scored by using the MCBS. Third, the ensuing results were evaluated within corresponding programme directorships to assess feasibility in a real-life clinical context. In the majority of tumour entities, the MCBS results reported earlier are consistent with daily clinical practice. Thus, in metastatic breast cancer or advanced lung cancer, there was a high level of clinical benefit for first-line treatment standards, and these results reflected well real-life experience. However, analyses based on the first version of the MCBS are limited if it comes to salvage treatment in tumour entities in which optimal sequencing of potential treatment options is of major importance, as in metastatic colorectal or renal cell cancer. In contrast to this, it is remarkable that certain novel therapies such as nivolumab assessed for heavily pretreated advanced renal cancer reached the highest level of clinical benefit due to prolongation in survival and a favourable toxicity profile. The MCBS clearly underlines the potential benefit of these compounds. The MCBS is an excellent tool for daily clinical practice of a tertiary referral centre. It supports treatment decisions based on the clinical benefit to be expected from a novel approach such as immunotherapy in as yet untested indications.

The Core Competencies for General Orthopaedic Surgeons.

PubMed

Kellam, James F; Archibald, Douglas; Barber, James W; Christian, Eugene P; D'Ascoli, Richard J; Haynes, Richard J; Hecht, Suzanne S; Hurwitz, Shepard R; Kellam, James F; McLaren, Alexander C; Peabody, Terrance D; Southworth, Stephen R; Strauss, Robert W; Wadey, Veronica M R

2017-01-18

With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist's care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual's higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one's practice based on experience, practice environment, and/or specialty interest. These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.

A Call for Innovation: Reflective Practices and Clinical Curricula of US Army Special Operations Forces Medics.

PubMed

Rocklein, Kate

2014-01-01

Special Operations Forces (SOF) medics have written and published numerous practice reflections that intricately describe their practice environments, clinical dilemmas, and suggestions for teaching and practice. The lack of translation of SOF medics experiential evidence to their curriculum has created a gap in evidence-based curriculum development. This study analyzed SOF medics learning and practice patterns and compared it to the evidence in the interdisciplinary clinical literature. After framing the problem, the literature was reviewed to determine appropriate tools by which perceptions and attitudes toward reflection-centered curricula could be measured. A recognizable practice reflection was extracted from the published SOF clinical literature and presented in writing to self-identified SOF medics and medic instructors via a descriptive crossover design, to ensure possible biases were mitigated. To measure SOF medics perceptions of reflection-based curricula, the Dundee Ready Education Environment Measure survey instrument was used, as it has validated psychometric properties and is used worldwide. SOF medics averaged scores of perceptions of their medic education indicated positive but not completely statistically significant preferences toward reflection-based curricula over traditional curriculum. Special Operations, medics, reflective practice, curricula BACKGROUND Special Operations Forces (SOF) medics practice in environments that are violent, austere, clandestine, and far removed from definitive hospital facilities. What was true almost 20 years ago?". . . academic demands of [Special Forces medic training] are roughly equivalent to those of an upper-level undergraduate curriculum in science or perhaps to those of first year medical school"?is even more challenging today. During this study, medics, physicians, and educators within the SOF medical community publicly and privately (ergo, names were redacted) expressed the need for curricular changes to teach SOF medics about the worst of clinical scenarios, such as situations in which evacuation of critically injured Soldiers to higher echelons of care is not possible or is prolonged, due to combat engagements or other complications. These experts consistently describe the need for curriculum derived from experienced medics practices, to guide force-wide knowledge acquisition and augment student medics professional development. Given the investigator?s clinical familiarity with SOF medics practice and evidence, senior, enlisted SOF medics and SOF medic instructors proposed that a doctoral-prepared nurse, whose clinical specialty was trauma, could spearhead academic focus and publication on the experiences and curriculum of SOF medics. 2014.

The quest to standardize hemodialysis care.

PubMed

Hegbrant, Jörgen; Gentile, Giorgio; Strippoli, Giovanni F M

2011-01-01

A large global dialysis provider's core activities include providing dialysis care with excellent quality, ensuring a low variability across the clinic network and ensuring strong focus on patient safety. In this article, we summarize the pertinent components of the quality assurance and safety program of the Diaverum Renal Services Group. Concerning medical performance, the key components of a successful quality program are setting treatment targets; implementing evidence-based guidelines and clinical protocols; consistently, regularly, prospectively and accurately collecting data from all clinics in the network; processing collected data to provide feedback to clinics in a timely manner, incorporating information on interclinic and intercountry variations; and revising targets, guidelines and clinical protocols based on sound scientific data. The key activities for ensuring patient safety include a standardized approach to education, i.e. a uniform education program including control of theoretical knowledge and clinical competencies; implementation of clinical policies and procedures in the organization in order to reduce variability and potential defects in clinic practice; and auditing of clinical practice on a regular basis. By applying a standardized and systematic continuous quality improvement approach throughout the entire organization, it has been possible for Diaverum to progressively improve medical performance and ensure patient safety. Copyright © 2011 S. Karger AG, Basel.

Barriers to implementing the "2008 Mexican Clinical Practice Guideline recommendations for the management of hip and knee osteoarthritis" in primary healthcare practice.

PubMed

Loyola-Sanchez, Adalberto; Richardson, Julie; Pelaez-Ballestas, Ingris; Sánchez, José Guadalupe; González, Martha Alicia; Sánchez-Cruz, Juan; Jiménez-Baez, María Valeria; Nolasco-Alonso, Nancy; Alvarado, Idolina; Rodríguez-Amado, Jacqueline; Alvarez-Nemegyei, José; Wilson, Mike G

2014-01-01

To evaluate the implementability of the "2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care" within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2). Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques. Reviewers' agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients' beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline. The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Ethical considerations in aesthetic rhinoplasty: a survey, critical analysis, and review.

PubMed

Karimi, Kian; McKneally, Martin F; Adamson, Peter A

2012-11-01

Although the practice of medicine is built on a foundation of ethics, science, and common sense, the increasing complexity of medical interventions, social interactions, and societal norms of behavior challenges the ethical practice of aesthetic surgeons. We report a survey of the opinions, practices, and attitudes of experienced and novice facial plastic surgeons. The survey consisted of 15 clinical vignettes addressing ethical quandaries in aesthetic rhinoplasty. The vignettes are based on the experience and observations of the senior author (P.A.A.) over nearly 30 years of practice and teaching. Fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed anonymously. Five of the 15 vignettes demonstrated significant differences between the responses of the fellowship directors and the fellows. No single vignette had a unanimous consensus in either group. Aesthetic rhinoplasty surgeons encounter ethical issues that should be reflected on by both experienced and inexperienced facial plastic surgeons, preferably before being faced with them in practice. We present a practical approach to ethical issues in clinical practice. Our survey can also be used as a stimulus for further discussion and teaching.

Probiotic guidelines and physician practice: a cross-sectional survey and overview of the literature.

PubMed

Draper, K; Ley, C; Parsonnet, J

2017-08-24

Probiotic use by patients and physicians has dramatically increased over the last decade, although definitive evidence is often lacking for their use. We examined probiotic-prescribing practices among health care providers (HCP) at a tertiary medical centre and compared these practices to clinical guidelines. HCP at the Stanford Medical Center received a survey on probiotic prescribing practices including choice of probiotic and primary indications. A broad overview of the literature was performed. Among 2,331 HCP surveyed, 632 responded. Of the 582 of these who routinely prescribed medications, 61% had recommended probiotic foods or supplements to their patients. Women and gastroenterologists were more likely to prescribe probiotics (odds ratio (OR): 1.5, 95% confidence interval (CI): 1.0-2.1; OR: 3.9, 95% CI: 1.5-10.1, respectively). Among probiotic prescribers, 50% prescribed inconsistently or upon patient request, and 40% left probiotic choice to the patient. Common indications for probiotics, particularly Lactobacillus GG, were prevention and treatment of antibiotic-associated diarrhoea (79 and 66%, respectively). Probiotics were often prescribed for 'general bowel health' or at patient request (27 and 39% of responders, respectively). Most respondents (63%) thought an electronic medical record (EMR) pop-up would change probiotic prescribing patterns. However, a review of published guidelines and large trials found inconsistencies in probiotic indications, dosages and strain selection. Probiotic prescribing is common but lacks consistency, with choice of probiotic frequently left to the patient, even for indications with some strain-specific evidence. Implementation of EMR pop-ups/pocket guides may increase consistency in probiotic prescribing, although the lack of clear and consistent guidelines must first be addressed with large, well-designed clinical trials.

Practice patterns of image guided particle therapy in Europe: A 2016 survey of the European Particle Therapy Network (EPTN).

PubMed

Bolsi, Alessandra; Peroni, Marta; Amelio, Dante; Dasu, Alexandru; Stock, Markus; Toma-Dasu, Iuliana; Nyström, Petra Witt; Hoffmann, Aswin

2018-03-28

Image guidance is critical in achieving accurate and precise radiation delivery in particle therapy, even more than in photon therapy. However, equipment, quality assurance procedures and clinical workflows for image-guided particle therapy (IGPT) may vary substantially between centres due to a lack of standardization. A survey was conducted to evaluate the current practice of IGPT in European particle therapy centres. In 2016, a questionnaire was distributed among 19 particle therapy centres in 12 European countries. The questionnaire consisted of 30 open and 37 closed questions related to image guidance in the general clinical workflow, for moving targets, current research activities and future perspectives of IGPT. All centres completed the questionnaire. The IGPT methods used by the 10 treating centres varied substantially. The 9 non-treating centres were in the process to introduce IGPT. Most centres have developed their own IGPT strategies, being tightly connected to their specific technical implementation and dose delivery methods. Insight into the current clinical practice of IGPT in European particle therapy centres was obtained. A variety in IGPT practices and procedures was confirmed, which underlines the need for harmonisation of practice parameters and consensus guidelines. Copyright © 2018 Elsevier B.V. All rights reserved.

Guidelines for psychological practice with older adults.

PubMed

2014-01-01

The "Guidelines for Psychological Practice With Older Adults" are intended to assist psychologists in evaluating their own readiness for working with older adults and in seeking and using appropriate education and training to increase their knowledge, skills, and experience relevant to this area of practice. The specific goals of these professional practice guidelines are to provide practitioners with (a) a frame of reference for engaging in clinical work with older adults and (b) basic information and further references in the areas of attitudes, general aspects of aging, clinical issues, assessment, intervention, consultation, professional issues, and continuing education and training relative to work with this group. The guidelines recognize and appreciate that there are numerous methods and pathways whereby psychologists may gain expertise and/or seek training in working with older adults. This document is designed to offer recommendations on those areas of awareness, knowledge, and clinical skills considered as applicable to this work, rather than prescribing specific training methods to be followed. The guidelines also recognize that some psychologists will specialize in the provision of services to older adults and may therefore seek more extensive training consistent with practicing within the formally recognized specialty of Professional Geropsychology (APA, 2010c). PsycINFO Database Record (c) 2014 APA, all rights reserved.

Appraising the methodological quality of the clinical practice guideline for diabetes mellitus using the AGREE II instrument: a methodological evaluation.

PubMed

Radwan, Mahmoud; Akbari Sari, Ali; Rashidian, Arash; Takian, Amirhossein; Abou-Dagga, Sanaa; Elsous, Aymen

2017-02-01

To evaluate the methodological quality of the Palestinian Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II. Methodological evaluation. A cross-cultural adaptation framework was followed to translate and develop a standardised Translated Arabic Version of the AGREE II. Palestinian Primary Healthcare Centres. Sixteen appraisers independently evaluated the Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II. Methodological quality of diabetic guideline. The Translated Arabic Version of the AGREE II showed an acceptable reliability and validity. Internal consistency ranged between 0.67 and 0.88 (Cronbach's α). Intra-class coefficient among appraisers ranged between 0.56 and 0.88. The quality of this guideline is low. Both domains 'Scope and Purpose' and 'Clarity of Presentation' had the highest quality scores (66.7% and 61.5%, respectively), whereas the scores for 'Applicability', 'Stakeholder Involvement', 'Rigour of Development' and 'Editorial Independence' were the lowest (27%, 35%, 36.5%, and 40%, respectively). The findings suggest that the quality of this Clinical Practice Guideline is disappointingly low. To improve the quality of current and future guidelines, the AGREE II instrument is extremely recommended to be incorporated as a gold standard for developing, evaluating or updating the Palestinian Clinical Practice Guidelines. Future guidelines can be improved by setting specific strategies to overcome implementation barriers with respect to economic considerations, engaging of all relevant end-users and patients, ensuring a rigorous methodology for searching, selecting and synthesising the evidences and recommendations, and addressing potential conflict of interests within the development group.

Post-deployment usability evaluation of a radiology workstation.

PubMed

Jorritsma, Wiard; Cnossen, Fokie; Dierckx, Rudi A; Oudkerk, Matthijs; Van Ooijen, Peter M A

2016-01-01

To determine the number, nature and severity of usability issues radiologists encounter while using a commercially available radiology workstation in clinical practice, and to assess how well the results of a pre-deployment usability evaluation of this workstation generalize to clinical practice. The usability evaluation consisted of semi-structured interviews and observations of twelve users using the workstation during their daily work. Usability issues and positive usability findings were documented. Each issue was given a severity rating and its root cause was determined. Results were compared to the results of a pre-deployment usability evaluation of the same workstation. Ninety-two usability issues were identified, ranging from issues that cause minor frustration or delay, to issues that cause significant delays, prevent users from completing tasks, or even pose a potential threat to patient safety. The results of the pre-deployment usability evaluation had limited generalizability to clinical practice. This study showed that radiologists encountered a large number and a wide variety of usability issues when using a commercially available radiology workstation in clinical practice. This underlines the need for effective usability engineering in radiology. Given the limitations of pre-deployment usability evaluation in radiology, which were confirmed by our finding that the results of a pre-deployment usability evaluation of this workstation had limited generalizability to clinical practice, it is vital that radiology workstation vendors devote significant resources to usability engineering efforts before deployment of their workstation, and to continue these efforts after the workstation is deployed in a hospital. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Why Physics in Medicine?

PubMed

Samei, Ehsan; Grist, Thomas M

2018-05-18

Despite its crucial role in the development of new medical imaging technologies, in clinical practice, physics has primarily been involved in the technical evaluation of technologies. However, this narrow role is no longer adequate. New trajectories in medicine call for a stronger role for physics in the clinic. The movement toward evidence-based, quantitative, and value-based medicine requires physicists to play a more integral role in delivering innovative precision care through the intentional clinical application of physical sciences. There are three aspects of this clinical role: technology assessment based on metrics as they relate to expected clinical performance, optimized use of technologies for patient-centered clinical outcomes, and retrospective analysis of imaging operations to ensure attainment of expectations in terms of quality and variability. These tasks fuel the drive toward high-quality, consistent practice of medical imaging that is patient centered, evidence based, and safe. While this particular article focuses on imaging, this trajectory and paradigm is equally applicable to the multitudes of the applications of physics in medicine. Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Clinical aspects of the Mayo/IBM PACS project

NASA Astrophysics Data System (ADS)

Forbes, Glenn S.; Morin, Richard L.; Pavlicek, William

1991-07-01

A joint project between Mayo Clinic and IBM to develop a picture archival and communications system has been under development for three years. This project began as a potential solution to a pressing archival problem in magnetic resonance imaging. The project has grown to encompass a much larger sphere of activity including workstations, image retrieval, and report archival. This report focuses on the clinical aspects involved in the design, development, and implementation of such a system. In particular, emphasis is placed on the clinical impact of the system both inside and outside of the radiology department. The primary concerns have centered on fidelity of archival data, ease of use, and diagnostic efficacy. The project to date has been limited to neuroradiology practice. This group consists of nine staff radiologists and fellows. Administrative policy decisions regarding the accessibility and available of digital data in the clinical environment have been much more difficult and complex than originally conceived. Based on the observations thus far, the authors believe the system will become a useful and valuable adjunct to clinical practice of radiology.

UK Survey of Clinical Consistency in Tracheostomy Management

ERIC Educational Resources Information Center

McGowan, Susan L.; Ward, Elizabeth C.; Wall, Laurelie R.; Shellshear, Leanne R.; Spurgin, Ann-Louise

2014-01-01

Background: Many speech and language therapists (SLTs) work with patients who have a tracheostomy. There is limited information about their working practices and the extent to which recent publications and research have influenced the speech and language therapy management of the tracheostomized patient. Aims: This study reviews the current…

A Thematic Inquiry into the Burnout Experience of Australian Solo-Practicing Clinical Psychologists.

PubMed

Hammond, Trent E; Crowther, Andrew; Drummond, Sally

2017-01-01

Objective: Burnout is conceptualized as a syndrome that consists of emotional exhaustion, depersonalization, and decreased personal accomplishment. Despite the increased frequency and severity of burnout in the Western world, there is limited published research regarding the experiences of clinical psychologists who have had burnout. The present study examines clinical psychologists' different experiences of burnout in Australia. Design and Methods: In the year 2015, six privately practicing and solo-employed clinical psychologists provided rich qualitative data by participating in semi-structured interviews. Thematic analysis was the method used to analyze clinical psychologists' natural accounts of their burnout experiences. Using NVivo, emerging themes were identified through coding 'first order constructs' and then axial code 'second order constructs.' Findings: Clinical psychologists indicated that their roles are demanding and a diverse range of symptoms, including the enduring effects of burnout, mental stress, fatigue, decreased personal accomplishment, negative affect, depersonalization, reduced productivity and motivation, and insomnia. They identified precursors of burnout, including excessive workload and hours of work, life stresses, mismanaged workload, and transference. Clinical psychologists suggested that protective factors of burnout include knowledge and years worked in direct care, and trusting and long-term relationships. They indicated that the barriers to overcoming burnout include the fallacy that their clients' expectations and needs are more important than their own, the financial cost of working in private practice, contemporary knowledge and inadequate education regarding self-care, and time constraints. Discussion and Conclusion: The findings presented in this study provide psychologists and other health professionals with an insight about the burnout experience and inform professionals of the mental shortcomings of working as a solo-practicing clinical psychologist. Findings from this study should lead to an increased understanding of the complexities of burnout, and ultimately reduced cases of burnout, absenteeism, and staff disengagement.

Cross-disciplinary research in cancer: an opportunity to narrow the knowledge–practice gap

PubMed Central

Urquhart, R.; Grunfeld, E.; Jackson, L.; Sargeant, J.; Porter, G.A.

2013-01-01

Health services researchers have consistently identified a gap between what is identified as “best practice” and what actually happens in clinical care. Despite nearly two decades of a growing evidence-based practice movement, narrowing the knowledge–practice gap continues to be a slow, complex, and poorly understood process. Here, we contend that cross-disciplinary research is increasingly relevant and important to reducing that gap, particularly research that encompasses the notion of transdisciplinarity, wherein multiple academic disciplines and non-academic individuals and groups are integrated into the research process. The assimilation of diverse perspectives, research approaches, and types of knowledge is potentially effective in helping research teams tackle real-world patient care issues, create more practice-based evidence, and translate the results to clinical and community care settings. The goals of this paper are to present and discuss cross-disciplinary approaches to health research and to provide two examples of how engaging in such research may optimize the use of research in cancer care. PMID:24311951

“At 150 kg, you can't run” men's weight loss stories in a popular health magazine provide appropriate examples of good health practice

PubMed Central

Couch, Danielle; Han, Gil-Soo; Robinson, Priscilla; Komesaroff, Paul

2014-01-01

We explore weight loss stories from 47 men collected from the Australian edition of Men's Health magazine between January 2009 and December 2012. Our analysis uses a mixed methods approach that combines thematic analysis and descriptive statistics to examine weight loss strategies against clinical practice guidelines for the management of overweight and obesity. All the stories reported the use of physical activity for weight loss and most stories detailed dietary changes for weight loss. Our findings indicate that most of the men reportedly used some form of behavioural strategies to assist them in their behaviour change efforts. The weight loss methods used were consistent with clinical practice guidelines, with the exception of some dietary practices. As narratives may assist with behaviour change, stories like those examined in this study could prove to be very useful in promoting weight loss to men. PMID:25750780

Knowledge of Radiation Hazards, Radiation Protection Practices and Clinical Profile of Health Workers in a Teaching Hospital in Northern Nigeria.

PubMed

Awosan, K J; Ibrahim, Mto; Saidu, S A; Ma'aji, S M; Danfulani, M; Yunusa, E U; Ikhuenbor, D B; Ige, T A

2016-08-01

Use of ionizing radiation in medical imaging for diagnostic and interventional purposes has risen dramatically in recent years with a concomitant increase in exposure of patients and health workers to radiation hazards. To assess the knowledge of radiation hazards, radiation protection practices and clinical profile of health workers in UDUTH, Sokoto, Nigeria. A cross-sectional study was conducted among 110 Radiology, Radiotherapy and Dentistry staff selected by universal sampling technique. The study comprised of administration of standardized semi-structured pre-tested questionnaire (to obtain information on socio-demographic characteristics, knowledge of radiation hazards, and radiation protection practices of participants), clinical assessment (comprising of chest X-ray, abdominal ultrasound and laboratory investigation on hematological parameters), and evaluation of radiation exposure of participants (extracted from existing hospital records on their radiation exposure status). The participants were aged 20 to 65 years (mean = 34.04 ± 8.83), most of them were males (67.3%) and married (65.7%). Sixty five (59.1%) had good knowledge of radiation hazards, 58 (52.7%) had good knowledge of Personal Protective Devices (PPDs), less than a third, 30 (27.3%) consistently wore dosimeter, and very few (10.9% and below) consistently wore the various PPDs at work. The average annual radiation exposure over a 4 year period ranged from 0.0475mSv to 1.8725mSv. Only 1 (1.2%) of 86 participants had abnormal chest X-ray findings, 8 (9.4%) of 85 participants had abnormal abdominal ultrasound findings; while 17 (15.5%) and 11 (10.0%) of 110 participants had anemia and leucopenia respectively. This study demonstrated poor radiation protection practices despite good knowledge of radiation hazards among the participants, but radiation exposure and prevalence of abnormal clinical conditions were found to be low. Periodic in-service training and monitoring on radiation safety was suggested.

Knowledge of Radiation Hazards, Radiation Protection Practices and Clinical Profile of Health Workers in a Teaching Hospital in Northern Nigeria

PubMed Central

Ibrahim, MTO; Saidu, SA; Ma’aji, SM; Danfulani, M; Yunusa, EU; Ikhuenbor, DB; Ige, TA

2016-01-01

Introduction Use of ionizing radiation in medical imaging for diagnostic and interventional purposes has risen dramatically in recent years with a concomitant increase in exposure of patients and health workers to radiation hazards. Aim To assess the knowledge of radiation hazards, radiation protection practices and clinical profile of health workers in UDUTH, Sokoto, Nigeria. Materials and Methods A cross-sectional study was conducted among 110 Radiology, Radiotherapy and Dentistry staff selected by universal sampling technique. The study comprised of administration of standardized semi-structured pre-tested questionnaire (to obtain information on socio-demographic characteristics, knowledge of radiation hazards, and radiation protection practices of participants), clinical assessment (comprising of chest X-ray, abdominal ultrasound and laboratory investigation on hematological parameters), and evaluation of radiation exposure of participants (extracted from existing hospital records on their radiation exposure status). Results The participants were aged 20 to 65 years (mean = 34.04 ± 8.83), most of them were males (67.3%) and married (65.7%). Sixty five (59.1%) had good knowledge of radiation hazards, 58 (52.7%) had good knowledge of Personal Protective Devices (PPDs), less than a third, 30 (27.3%) consistently wore dosimeter, and very few (10.9% and below) consistently wore the various PPDs at work. The average annual radiation exposure over a 4 year period ranged from 0.0475mSv to 1.8725mSv. Only 1 (1.2%) of 86 participants had abnormal chest X-ray findings, 8 (9.4%) of 85 participants had abnormal abdominal ultrasound findings; while 17 (15.5%) and 11 (10.0%) of 110 participants had anemia and leucopenia respectively. Conclusion This study demonstrated poor radiation protection practices despite good knowledge of radiation hazards among the participants, but radiation exposure and prevalence of abnormal clinical conditions were found to be low. Periodic in-service training and monitoring on radiation safety was suggested. PMID:27656470

Health professionals' decision-making in wound management: a grounded theory.

PubMed

Gillespie, Brigid M; Chaboyer, Wendy; St John, Winsome; Morley, Nicola; Nieuwenhoven, Paul

2015-06-01

To develop a conceptual understanding of the decision-making processes used by healthcare professionals in wound care practice. With the global move towards using an evidence-base in standardizing wound care practices and the need to reduce hospital wound care costs, it is important to understand health professionals' decision-making in this important yet under-researched area. A grounded theory approach was used to explore clinical decision-making of healthcare professionals in wound care practice. Interviews were conducted with 20 multi-disciplinary participants from nursing, surgery, infection control and wound care who worked at a metropolitan hospital in Australia. Data were collected during 2012-2013. Constant comparative analysis underpinned by Strauss and Corbin's framework was used to identify clinical decision-making processes. The core category was 'balancing practice-based knowledge with evidence-based knowledge'. Participants' clinical practice and actions embedded the following processes: 'utilizing the best available information', 'using a consistent approach in wound assessment' and 'using a multidisciplinary approach'. The substantive theory explains how practice and evidence knowledge was balanced and the variation in use of intuitive practice-based knowledge versus evidence-based knowledge. Participants considered patients' needs and preferences, costs, outcomes, technologies, others' expertise and established practices. Participants' decision-making tended to be more heavily weighted towards intuitive practice-based processes. These findings offer a better understanding of the processes used by health professionals' in their decision-making in wound care. Such an understanding may inform the development of evidence-based interventions that lead to better patient outcomes. © 2014 John Wiley & Sons Ltd.

Impact of a dedicated cancer-associated thrombosis service on clinical outcomes: a mixed-methods evaluation of a clinical improvement exercise

PubMed Central

Noble, Simon; Pease, Nikki; Sui, Jessica; Davies, James; Lewis, Sarah; Malik, Usman; Alikhan, Raza; Prout, Hayley; Nelson, Annmarie

2016-01-01

Objectives Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation. Setting Specialist cancer centre, district general hospital and primary care. Participants Patients with CAT and their referring clinicians. Intervention A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic. Primary and secondary outcome measures The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals. Results Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management. Conclusions A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care. PMID:27895068

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care.

PubMed

Boisvert, Isabelle; Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices.

Interpretation of medical information acts by UK occupational physicians.

PubMed

Batty, Lucia; Glozier, Nick; Holland-Elliott, Kevin

2009-05-01

Difficulties arise in applying the Data Protection Act 1998 and the Access to Medical Reports Act 1988 in occupational health practice. There is no guidance on detailed aspects of applying these Acts in practice and consistent advice has proved difficult to obtain. To audit the understanding and practice of UK occupational physicians to see if a consensus view existed. A postal questionnaire sent to all UK-based Society of Occupational Medicine (SOM) members between December 2005 and June 2006. Responses were analysed using the SPSS 13.0 software. Responses were received from 726 SOM members, a response rate of 48%. The study revealed wide variation and a limited consensus in practice. Significant differences existed between doctors with a Diploma in Occupational Medicine and those with higher Faculty qualifications, between part-time and full-time practitioners and between doctors who qualified pre- and post-1974. The audit revealed wide variation in responding to clinical scenarios in relation to both the Access to Medical Reports and the Data Protection Acts. The findings have implications for clinical practice, policy and research. The majority of respondents reported that national guidance is needed.

Perspectives on Technology-Assisted Relaxation Approaches to Support Mind-Body Skills Practice in Children and Teens: Clinical Experience and Commentary.

PubMed

Culbert, Timothy

2017-04-04

It has been well-established that a variety of mind-body (MB) techniques, including yoga, mental imagery, hypnosis, biofeedback, and meditation, are effective at addressing symptoms such as pain, anxiety, nausea, and insomnia, as well as helping with a wide variety of medical, emotional, and behavioral issues in pediatric populations. In addition, MB skills can also be health promoting in the long-term, and with regular practice, could potentially contribute to longer attention spans, social skills, emotional regulation, and enhanced immune system functioning. Importantly, the benefits accrued from MB skills are largely dose dependent, meaning that individuals who practice with some consistency tend to benefit the most, both in the short- and long-term. However, clinical experience suggests that for busy patients, the regular practice of MB skills can be challenging and treatment adherence commonly becomes an issue. This commentary reviews the concept of technology assisted relaxation as an engaging and effective option to enhance treatment adherence (i.e., daily practice) for pediatric patients, for whom MB skills have been recommended to address physical and mental health challenges.

[Quality standards for ultrasound assessment of the superficial venous system of the lower limbs. Report of the French Society for Vascular Medicine].

PubMed

Auvert, J-F; Chleir, F; Coppé, G; Hamel-Desnos, C; Moraglia, L; Pichot, O

2014-02-01

The quality standards of the French Society for Vascular Medicine for the ultrasound assessment of the superficial venous system of the lower limbs are based on the two following requirements: technical know-how (mastering the use of ultrasound devices and the method of examination); medical know-how (ability to adapt the methods and scope of the examination to its clinical indications and purpose and to rationally analyze and interpret its results). To describe an optimal method of examination in relation to the clinical question and hypothesis; to achieve consistent practice, methods, glossary terminologies and reporting; to provide good practice reference points and to promote a high quality process. The three levels of examination. Their clinical indications and goals. The reference standard examination (level 2) and its variants according to clinical needs. The minimal content of the examination report, the letter to the referring physician (synthesis, conclusion and management suggestions) and iconography. Commented glossary (anatomy, hemodynamics, semiology). Technical basis. Ultrasound devices settings. We discuss of use of Duplex ultrasound for the assessment of the superficial veins of the lower limbs in vascular medicine practice. Copyright © 2014. Published by Elsevier Masson SAS.

A continuous quality improvement approach to improving clinical practice in the areas of sedation, analgesia, and neuromuscular blockade.

PubMed

Arbour, Richard

2003-01-01

Practice concerns associated with the medical prescription and nurses' administration and monitoring of sedatives, analgesics, and neuromuscular blocking agents were identified by the clinical nurse specialist within a surgical intensive care unit of a large, tertiary-care referral center. These concerns were identified using a variety of needs assessment strategies. Results of the needs assessment were used to develop a program of care, including a teaching initiative, specific to these practice areas. The teaching initiative incorporated principles of andragogy, the theory of adult learning. Educational techniques included inservice education, bedside instruction using "teaching moments," competency-based education modules, and integration of instruction into critical care orientation. Content and approach were based on the background and level of experience of participants. Educational program outcomes included increased consistency in monitoring neuromuscular blockade by clinical assessment and peripheral nerve stimulation. A second outcome was more accurate patient assessment leading to the provision of drug therapy specific to the patients' clinical states, including anxiety or pain. The continuous quality improvement approach offers a model for improving patient care using individualized needs assessment, focused educational interventions, and program evaluation strategies.

Red flag screening for low back pain: nothing to see here, move along: a narrative review.

PubMed

Cook, Chad E; George, Steven Z; Reiman, Michael P

2018-04-01

Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Translation and validation of the clinical learning environment, supervision and nurse teacher scale (CLES + T) in Croatian language.

PubMed

Lovrić, Robert; Piškorjanac, Silvija; Pekić, Vlasta; Vujanić, Jasenka; Ratković, Karolina Kramarić; Luketić, Suzana; Plužarić, Jadranka; Matijašić-Bodalec, Dubravka; Barać, Ivana; Žvanut, Boštjan

2016-07-01

Clinical practice is essential to nursing education as it provides experience with patients and work environments that prepare students for future work as nurses. The aim of this study was to translate the "Clinical Learning Environment, Supervision and Nurse Teacher" questionnaire in Croatian language and test its validity and reliability in practice. The study was performed at the Faculty of medicine, Josip Juraj Strossmayer University of Osijek, Croatia in April 2014. The translated questionnaire was submitted to 136 nursing students: 20 males and 116 females. Our results reflected a slightly different factor structure, consisting of four factors. All translated items of the original constructs "Supervisory relationship", "Role of nurse teacher" and "Leadership style of the ward manager" loaded on factor 1. Items of "Pedagogical atmosphere on the ward" are distributed on two factors (3 and 4). The items of "Premises of nursing on the ward" loaded on factor 2. Three items were identified as problematic and iteratively removed from the analysis. The translated version of the aforementioned questionnaire has properties suitable for the evaluation of clinical practice for nursing students within a Croatian context and reflects the specifics of the nursing clinical education in this country. Copyright © 2016 Elsevier Ltd. All rights reserved.

H. pylori and Barrett's Esophagus: Implications for Populations and Practice.

PubMed

Howden, Colin W

2018-06-19

In this edition of the American Journal of Gastroenterology, Wang and colleagues report the results of an analysis of six different case-control studies examining the relationship between Helicobacter pylori (H. pylori) infection and Barrett's esophagus. They present a cogent argument that there is an inverse association between these two that is mediated via GERD. This is broadly consistent with previous reports. While further establishing this inverse association, the findings should not materially influence our routine clinical practice regarding GERD or H. pylori infection.

Translating Pressure Ulcer Prevention Into Intensive Care Nursing Practice: Overlaying a Care Bundle Approach With a Model for Research Implementation.

PubMed

Tayyib, Nahla; Coyer, Fiona

This article reports on the development and implementation process used to integrate a care bundle approach (a pressure ulcer [PU] prevention bundle to improve patients' skin integrity in intensive care) and the Ottawa Model of Research Use (OMRU). The PU prevention care bundle demonstrated significant reduction in PU incidence, with the OMRU model providing a consolidated framework for the implementation of bundled evidence in an effective and consistent manner into daily clinical nursing practice.

Touchscreen questionnaire patient data collection in rheumatology practice: development of a highly successful system using process redesign.

PubMed

Newman, Eric D; Lerch, Virginia; Jones, J B; Stewart, Walter

2012-04-01

While questionnaires have been developed to capture patient-reported outcomes (PROs) in rheumatology practice, these instruments are not widely used. We developed a touchscreen interface designed to provide reliable and efficient data collection. Using the touchscreen to obtain PROs, we compared 2 different workflow models implemented separately in 2 rheumatology clinics. The Plan-Do-Study-Act methodology was used in 2 cycles of workflow redesign. Cycle 1 relied on off-the-shelf questionnaire builder software, and cycle 2 relied on a custom programmed software solution. During cycle 1, clinic 1 (private practice model, resource replete, simple flow) demonstrated a high completion rate at the start, averaging between 74% and 92% for the first 12 weeks. Clinic 2 (academic model, resource deficient, complex flow) did not achieve a consistent completion rate above 60%. The revised cycle 2 implementation protocol incorporated a 15-minute "nurse visit," an instant messaging system, and a streamlined authentication process, all of which contributed to substantial improvement in touchscreen questionnaire completion rates of ∼80% that were sustained without the need for any additional clinic staff support. Process redesign techniques and touchscreen technology were used to develop a highly successful, efficient, and effective process for the routine collection of PROs in a busy, complex, and resource-depleted academic practice and in typical private practice. The successful implementation required both a touchscreen questionnaire, human behavioral redesign, and other technical solutions. Copyright © 2012 by the American College of Rheumatology.

A systematic review of clinical practice guidelines and best practice statements for the diagnosis and management of varicocele in children and adolescents.

PubMed

Roque, Matheus; Esteves, Sandro C

2016-01-01

A systematic review was conducted to identify and qualitatively analyze the methods as well as recommendations of Clinical Practice Guidelines (CPG) and Best Practice Statements (BPS) concerning varicocele in the pediatric and adolescent population. An electronic search was performed with the MEDLINE, EMBASE, Science Direct, and Scielo databases, as well as guidelines' Web sites until September 2015. Four guidelines were included in the qualitative synthesis. In general, the recommendations provided by the CPG/BPS were consistent despite the existence of some gaps across the studies. The guidelines issued by the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) did not provide evidence-based levels for the recommendations given. Most of the recommendations given by the European Association of Urology (EAU) and European Society of Pediatric Urology (ESPU) were derived from nonrandomized clinical trials, retrospective studies, and expert opinion. Among all CPG/BPS, only one was specifically designed for the pediatric population. The studied guidelines did not undertake independent cost-effectiveness and risk-benefit analysis. The main objectives of these guidelines were to translate the best evidence into practice and provide a framework of standardized care while maintaining clinical autonomy and physician judgment. However, the limitations identified in the CPG/BPS for the diagnosis and management of varicocele in children and adolescents indicate ample opportunities for research and future incorporation of higher quality standards in patient care.

Doctors' experience with handheld computers in clinical practice: qualitative study

PubMed Central

McAlearney, Ann Scheck; Schweikhart, Sharon B; Medow, Mitchell A

2004-01-01

Objective To examine doctors' perspectives about their experiences with handheld computers in clinical practice. Design Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns. Setting Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists. Participants 54 doctors who did or did not use handheld computers. Results Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking. Conclusions Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care. PMID:15142920

Alosetron use in clinical practice: significant improvement in irritable bowel syndrome symptoms evaluated using the US Food and Drug Administration composite endpoint.

PubMed

Lacy, Brian E; Nicandro, Jean Paul; Chuang, Emil; Earnest, David L

2018-01-01

Alosetron is approved to treat women with severe IBS and diarrhea (IBS-D) who have failed standard therapy. In our study, we aimed to evaluate alosetron efficacy using new US Food and Drug Administration (FDA) endpoints and utilization in clinical practice. This prospective, open-label, multicenter, observational 12-week study evaluated women with severe IBS-D enrolled in the alosetron prescribing program. The coprimary FDA endpoints were changes from baseline in stool consistency and abdominal pain severity. Responders achieved a 30% decrease compared with baseline in weekly average of the worst abdominal pain in the past 24 h, and a 50% or greater reduction from baseline in the number of days/week with at least one stool of type 6 (mushy) or type 7 (watery) consistency. Secondary endpoints included changes from baseline in stool frequency, fecal urgency and fecal incontinence. Enrolled patients ( n = 192) were primarily White (90.6%), with a mean age of 44.5 years. Patient and physician rating of IBS severity was between moderate and severe (85.9% concordance, Spearman coefficient 0.429, p < 0.0001). Alosetron 0.5 mg twice daily (82.8%) was the most common dosing regimen. A total of 152 alosetron-treated patients completed the study. Of 105 fully evaluable patients, 45% met the FDA composite endpoint responder criteria for ⩾50% of the study period. Improvements in all individual symptoms were statistically significant compared with baseline. There were no serious adverse events, cases of colonic ischemia, or complications of constipation. In a clinical practice setting study, alosetron demonstrated treatment success using a rigorous FDA composite endpoint and also improved multiple other IBS symptoms, including fecal urgency and incontinence in women with severe IBS-D [ClinicalTrials.gov identifier: NCT01257477].

Undue industry influences that distort healthcare research, strategy, expenditure and practice: a review.

PubMed

Stamatakis, Emmanuel; Weiler, Richard; Ioannidis, John P A

2013-05-01

Expenditure on industry products (mostly drugs and devices) has spiraled over the last 15 years and accounts for substantial part of healthcare expenditure. The enormous financial interests involved in the development and marketing of drugs and devices may have given excessive power to these industries to influence medical research, policy, and practice. Review of the literature and analysis of the multiple pathways through which the industry has directly or indirectly infiltrated the broader healthcare systems. We present the analysis of the industry influences at the following levels: (i) evidence base production, (ii) evidence synthesis, (iii) understanding of safety and harms issues, (iv) cost-effectiveness evaluation, (v) clinical practice guidelines formation, (vi) healthcare professional education, (vii) healthcare practice, (viii) healthcare consumer's decisions. We located abundance of consistent evidence demonstrating that the industry has created means to intervene in all steps of the processes that determine healthcare research, strategy, expenditure, practice and education. As a result of these interferences, the benefits of drugs and other products are often exaggerated and their potential harms are downplayed, and clinical guidelines, medical practice, and healthcare expenditure decisions are biased. To serve its interests, the industry masterfully influences evidence base production, evidence synthesis, understanding of harms issues, cost-effectiveness evaluations, clinical practice guidelines and healthcare professional education and also exerts direct influences on professional decisions and health consumers. There is an urgent need for regulation and other action towards redefining the mission of medicine towards a more objective and patient-, population- and society-benefit direction that is free from conflict of interests. © 2013 Stichting European Society for Clinical Investigation Journal Foundation. Published by Blackwell Publishing Ltd.

Adherence to COPD guidelines in general practice: impact of an educational programme delivered on location in Danish general practices.

PubMed

Ulrik, Charlotte Suppli; Sørensen, Tina Brandt; Højmark, Torben Brunse; Olsen, Kim Rose; Vedsted, Peter

2013-03-01

The general practitioner (GP) is often the first healthcare contact for patients with chronic obstructive pulmonary disease (COPD). To determine whether participating in a standardised educational programme delivered in the GP's own practice is associated with adherence to COPD guidelines. A nationwide register-based observational before and after study was undertaken with a control group of propensity-matched practices (follow-up period 6 months). COPD was defined as age 40+ years and at least two prescriptions for inhaled medication. The educational programme consisted of a 3-hr teaching lesson with a respiratory specialist and five visits by a representative from the sponsoring pharmaceutical company focusing on assessment and management of patients including written algorithms. A one-to-one propensity-matched control group of practices was selected. Register data were used to compare the rate of spirometry testing, preventive consultations, and influenza vaccinations provided to COPD patients and the rate of spirometry testing in non-COPD individuals, assumed to reflect diagnostic activity. Data for 102 participating GP practices were analysed. Participating clinics had a significant increase in preventive consultations and influenza vaccinations (p<0.05). For the control group, a significant change was observed only for influenza vaccinations. No significant change was found when comparing participating and control clinics in the difference-in-difference estimator. However, a significant improvement was observed for the subgroup of 48 clinics with the lowest starting point of spirometry testing. Focused education of GPs and their staff delivered in the GPs' own practices may improve adherence to COPD guidelines, not least for clinics with a high potential for improvement.

To Refer or Not to Refer: Exploring Family Therapists' Beliefs and Practices Related to the Referral of Lesbian, Gay, and Bisexual Clients.

PubMed

McGeorge, Christi R; Stone Carlson, Thomas; Farrell, Molly

2016-07-01

This study explored how negative beliefs toward lesbian, gay, and bisexual (LGB) individuals and LGB clinical competence influenced family therapists' beliefs and practices regarding referring based on the sexual orientation of the client. The sample consisted of 741 experienced clinicians. The results of this study indicated that the majority of the participants believe it is ethical to refer LGB clients; however, most had never made such a referral. Furthermore, participants who had referred based solely on the client's sexual orientation reported higher levels of negative beliefs toward LGB individuals and lower levels of LGB clinical competence. Finally, negative beliefs toward LGB persons not only predicted the practice of referring, but also the belief that it is ethical to refer an LGB client. © 2015 American Association for Marriage and Family Therapy.

Occupational stress among Swedish audiologists in clinical practice: Reasons for being stressed.

PubMed

Brännström, K Jonas; Holm, Lucas; Larsson, Josefina; Lood, Sofie; Notsten, Margareta; Turunen Taheri, Satu

2016-08-01

The present study reports on the application of a Swedish translation of the audiologist occupational stress questionnaire (AOSQ) on audiologists working in Sweden. The relations between AOSQ scores and perceived effort, perceived rewards, coping strategies at work, demographic variables such as salary, education length, practise length, and practice type were tested. A cross-sectional e-mail survey using the AOSQ, effort-reward imbalance questionnaire, and demographic questions. Four-hundred and four Swedish licensed audiologists working with clients. The Swedish AOSQ translation demonstrated high inter-item correlations and high internal consistency. Several stress factors were identified: time spent at work, accountability, leadership at the workplace, paperwork and practice demands, equipment and clinical protocols, own health concerns, and job control. The outcome on the complete AOSQ questionnaire was related to perceived effort, perceived rewards, coping strategies at work, and age. The Swedish AOSQ translation seems to provide a valid measure of occupational stress among audiologists.

Information in medical decision making: how consistent is our management?

PubMed

Lorence, Daniel P; Spink, Amanda; Jameson, Robert

2002-01-01

The use of outcomes data in clinical environments requires a correspondingly greater variety of information used in decision making, the measurement of quality, and clinical performance. As information becomes integral in the decision-making process, trustworthy decision support data are required. Using data from a national census of certified health information managers, variation in automated data quality management practices was examined. Relatively low overall adoption of automated data management exists in health care organizations, with significant geographic and practice setting variation. Nonuniform regional adoption of computerized data management exists, despite national mandates that promote and in some cases require uniform adoption. Overall, a significant number of respondents (42.7%) indicated that they had not adopted policies and procedures to direct the timeliness of data capture, with 57.3% having adopted such practices. The inconsistency of patient data policy suggests that provider organizations do not use uniform information management methods, despite growing federal mandates to do so.

Nurse teacher models in clinical education from the perspective of student nurses--A mixed method study.

PubMed

Gustafsson, Margareta; Kullén Engström, Agneta; Ohlsson, Ulla; Sundler, Annelie J; Bisholt, Birgitta

2015-12-01

The aim was to describe and compare the clinical teacher's role in different models of clinical practice from the perspective of student nurses. The study took place in collaboration with two Swedish universities that applied different educational models in clinical practice. A mixed method approach was used. The quantitative part had a comparative design and the qualitative part had a descriptive design. The study group consisted of 114 student nurses (response rate 87%). Fifty-three of them had met clinical teachers employed at the university and not participating in the daily clinical work (University Nurse Teachers, UNTs), whilst 61 had met clinical teachers dividing their time between teaching and nursing (Clinical Nurse Teachers, CNTs). Eight students participated in the qualitative part of the study. A questionnaire including the CLES+T scale was used to ascertain the students' perception of the clinical teacher's role, complemented by interviews directed towards an enrichment of this perception. Students meeting CNTs agreed more strongly than those meeting UNTs that the teacher had the ability to help them integrate theory and practice. Whilst spontaneous meetings between students and CNTs occurred, students mostly met UNTs in seminars. Students meeting UNTs felt alone but did appreciate having someone outside the clinical environment to provide support if they did not get along with their preceptor. In the case of UNTs, it is important that they keep their knowledge of clinical issues updated and visit the clinical placement not only for seminars but also to give students emotional support. In the case of CNTs, it is important that they are members of the faculty at the university, take part in the planning of the clinical courses and are able to explain the learning goals to the students. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Experience of the Mexican National Health System in the development of clinical practice guidelines].

PubMed

Sosa-García, Jesús Ojino; Nieves-Hernández, Pedro; Puentes-Rosas, Esteban; Pineda-Pérez, Dayana; Viniegra-Osorio, Arturo; Torres-Arreola, Laura del Pilar; Valenzuela-Flores, Adriana Abigail; Barragán-Padilla, Sergio Baltazar; Díaz-González, Ruth; Chávez-Valdez, Lizbeth; Ramírez-López, Juan Carlos

2016-01-01

Clinical practice guidelines are tools that have been able to streamline decisions made in health issues and to decrease the gap between clinical action and scientific evidence. The objective of the study is to share the experience in the development and to update the guidelines by the National Health System of Mexico. The methodology in the development of the guidelines consists of 5 phases: prioritisation, establishment of work groups, development by adoption of international guidelines of de novo, validation and integration in the Master catalogue of clinical practice guidelines for its dissemination. The Master catalogue of clinical practice guidelines contains 664 guidelines, distributed in 42% Internal Medicine, 22% Surgery, 24% Pediatrics and 12% Gynecology. From the total of guidelines coverage is granted at an 85% of the Universal catalogue of health services, an 84% of the Catastrophic expenses protection fund and a 61% of the XXI Century Medical Insurance of the National Commission of Social Protection in Health. The result is the sum of a great effort of coordination and cooperation between the institutions of the National Health System, political wills and a commitment of 3,477 health professionals that participate in guidelines' development and update. Master catalogue guidelines' integration, diffusion and implantation improve quality of attention and security of the users of the National Health System. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

An international effort towards developing standards for best practices in analysis, interpretation and reporting of clinical genome sequencing results in the CLARITY Challenge.

PubMed

Brownstein, Catherine A; Beggs, Alan H; Homer, Nils; Merriman, Barry; Yu, Timothy W; Flannery, Katherine C; DeChene, Elizabeth T; Towne, Meghan C; Savage, Sarah K; Price, Emily N; Holm, Ingrid A; Luquette, Lovelace J; Lyon, Elaine; Majzoub, Joseph; Neupert, Peter; McCallie, David; Szolovits, Peter; Willard, Huntington F; Mendelsohn, Nancy J; Temme, Renee; Finkel, Richard S; Yum, Sabrina W; Medne, Livija; Sunyaev, Shamil R; Adzhubey, Ivan; Cassa, Christopher A; de Bakker, Paul I W; Duzkale, Hatice; Dworzyński, Piotr; Fairbrother, William; Francioli, Laurent; Funke, Birgit H; Giovanni, Monica A; Handsaker, Robert E; Lage, Kasper; Lebo, Matthew S; Lek, Monkol; Leshchiner, Ignaty; MacArthur, Daniel G; McLaughlin, Heather M; Murray, Michael F; Pers, Tune H; Polak, Paz P; Raychaudhuri, Soumya; Rehm, Heidi L; Soemedi, Rachel; Stitziel, Nathan O; Vestecka, Sara; Supper, Jochen; Gugenmus, Claudia; Klocke, Bernward; Hahn, Alexander; Schubach, Max; Menzel, Mortiz; Biskup, Saskia; Freisinger, Peter; Deng, Mario; Braun, Martin; Perner, Sven; Smith, Richard J H; Andorf, Janeen L; Huang, Jian; Ryckman, Kelli; Sheffield, Val C; Stone, Edwin M; Bair, Thomas; Black-Ziegelbein, E Ann; Braun, Terry A; Darbro, Benjamin; DeLuca, Adam P; Kolbe, Diana L; Scheetz, Todd E; Shearer, Aiden E; Sompallae, Rama; Wang, Kai; Bassuk, Alexander G; Edens, Erik; Mathews, Katherine; Moore, Steven A; Shchelochkov, Oleg A; Trapane, Pamela; Bossler, Aaron; Campbell, Colleen A; Heusel, Jonathan W; Kwitek, Anne; Maga, Tara; Panzer, Karin; Wassink, Thomas; Van Daele, Douglas; Azaiez, Hela; Booth, Kevin; Meyer, Nic; Segal, Michael M; Williams, Marc S; Tromp, Gerard; White, Peter; Corsmeier, Donald; Fitzgerald-Butt, Sara; Herman, Gail; Lamb-Thrush, Devon; McBride, Kim L; Newsom, David; Pierson, Christopher R; Rakowsky, Alexander T; Maver, Aleš; Lovrečić, Luca; Palandačić, Anja; Peterlin, Borut; Torkamani, Ali; Wedell, Anna; Huss, Mikael; Alexeyenko, Andrey; Lindvall, Jessica M; Magnusson, Måns; Nilsson, Daniel; Stranneheim, Henrik; Taylan, Fulya; Gilissen, Christian; Hoischen, Alexander; van Bon, Bregje; Yntema, Helger; Nelen, Marcel; Zhang, Weidong; Sager, Jason; Zhang, Lu; Blair, Kathryn; Kural, Deniz; Cariaso, Michael; Lennon, Greg G; Javed, Asif; Agrawal, Saloni; Ng, Pauline C; Sandhu, Komal S; Krishna, Shuba; Veeramachaneni, Vamsi; Isakov, Ofer; Halperin, Eran; Friedman, Eitan; Shomron, Noam; Glusman, Gustavo; Roach, Jared C; Caballero, Juan; Cox, Hannah C; Mauldin, Denise; Ament, Seth A; Rowen, Lee; Richards, Daniel R; San Lucas, F Anthony; Gonzalez-Garay, Manuel L; Caskey, C Thomas; Bai, Yu; Huang, Ying; Fang, Fang; Zhang, Yan; Wang, Zhengyuan; Barrera, Jorge; Garcia-Lobo, Juan M; González-Lamuño, Domingo; Llorca, Javier; Rodriguez, Maria C; Varela, Ignacio; Reese, Martin G; De La Vega, Francisco M; Kiruluta, Edward; Cargill, Michele; Hart, Reece K; Sorenson, Jon M; Lyon, Gholson J; Stevenson, David A; Bray, Bruce E; Moore, Barry M; Eilbeck, Karen; Yandell, Mark; Zhao, Hongyu; Hou, Lin; Chen, Xiaowei; Yan, Xiting; Chen, Mengjie; Li, Cong; Yang, Can; Gunel, Murat; Li, Peining; Kong, Yong; Alexander, Austin C; Albertyn, Zayed I; Boycott, Kym M; Bulman, Dennis E; Gordon, Paul M K; Innes, A Micheil; Knoppers, Bartha M; Majewski, Jacek; Marshall, Christian R; Parboosingh, Jillian S; Sawyer, Sarah L; Samuels, Mark E; Schwartzentruber, Jeremy; Kohane, Isaac S; Margulies, David M

2014-03-25

There is tremendous potential for genome sequencing to improve clinical diagnosis and care once it becomes routinely accessible, but this will require formalizing research methods into clinical best practices in the areas of sequence data generation, analysis, interpretation and reporting. The CLARITY Challenge was designed to spur convergence in methods for diagnosing genetic disease starting from clinical case history and genome sequencing data. DNA samples were obtained from three families with heritable genetic disorders and genomic sequence data were donated by sequencing platform vendors. The challenge was to analyze and interpret these data with the goals of identifying disease-causing variants and reporting the findings in a clinically useful format. Participating contestant groups were solicited broadly, and an independent panel of judges evaluated their performance. A total of 30 international groups were engaged. The entries reveal a general convergence of practices on most elements of the analysis and interpretation process. However, even given this commonality of approach, only two groups identified the consensus candidate variants in all disease cases, demonstrating a need for consistent fine-tuning of the generally accepted methods. There was greater diversity of the final clinical report content and in the patient consenting process, demonstrating that these areas require additional exploration and standardization. The CLARITY Challenge provides a comprehensive assessment of current practices for using genome sequencing to diagnose and report genetic diseases. There is remarkable convergence in bioinformatic techniques, but medical interpretation and reporting are areas that require further development by many groups.

An international effort towards developing standards for best practices in analysis, interpretation and reporting of clinical genome sequencing results in the CLARITY Challenge

PubMed Central

2014-01-01

Background There is tremendous potential for genome sequencing to improve clinical diagnosis and care once it becomes routinely accessible, but this will require formalizing research methods into clinical best practices in the areas of sequence data generation, analysis, interpretation and reporting. The CLARITY Challenge was designed to spur convergence in methods for diagnosing genetic disease starting from clinical case history and genome sequencing data. DNA samples were obtained from three families with heritable genetic disorders and genomic sequence data were donated by sequencing platform vendors. The challenge was to analyze and interpret these data with the goals of identifying disease-causing variants and reporting the findings in a clinically useful format. Participating contestant groups were solicited broadly, and an independent panel of judges evaluated their performance. Results A total of 30 international groups were engaged. The entries reveal a general convergence of practices on most elements of the analysis and interpretation process. However, even given this commonality of approach, only two groups identified the consensus candidate variants in all disease cases, demonstrating a need for consistent fine-tuning of the generally accepted methods. There was greater diversity of the final clinical report content and in the patient consenting process, demonstrating that these areas require additional exploration and standardization. Conclusions The CLARITY Challenge provides a comprehensive assessment of current practices for using genome sequencing to diagnose and report genetic diseases. There is remarkable convergence in bioinformatic techniques, but medical interpretation and reporting are areas that require further development by many groups. PMID:24667040

Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management.

PubMed

Cappellini, Maria Domenica; Comin-Colet, Josep; de Francisco, Angel; Dignass, Axel; Doehner, Wolfram; Lam, Carolyn S; Macdougall, Iain C; Rogler, Gerhard; Camaschella, Clara; Kadir, Rezan; Kassebaum, Nicholas J; Spahn, Donat R; Taher, Ali T; Musallam, Khaled M

2017-10-01

Iron deficiency, even in the absence of anemia, can be debilitating, and exacerbate any underlying chronic disease, leading to increased morbidity and mortality. Iron deficiency is frequently concomitant with chronic inflammatory disease; however, iron deficiency treatment is often overlooked, partially due to the heterogeneity among clinical practice guidelines. In the absence of consistent guidance across chronic heart failure, chronic kidney disease and inflammatory bowel disease, we provide practical recommendations for iron deficiency to treating physicians: definition, diagnosis, and disease-specific diagnostic algorithms. These recommendations should facilitate appropriate diagnosis and treatment of iron deficiency to improve quality of life and clinical outcomes. © 2017 The Authors American Journal of Hematology Published by Wiley Periodicals, Inc.

Mesenchymal Stem Cells in Lipogems, a Reverse Story: from Clinical Practice to Basic Science.

PubMed

Tremolada, Carlo; Ricordi, Camillo; Caplan, Arnold I; Ventura, Carlo

2016-01-01

The idea that basic science should be the starting point for modern clinical approaches has been consolidated over the years, and emerged as the cornerstone of Molecular Medicine. Nevertheless, there is increasing concern over the low efficiency and inherent costs related to the translation of achievements from the bench to the bedside. These burdens are also perceived with respect to the effectiveness of translating basic discoveries in stem cell biology to the newly developing field of advanced cell therapy or Regenerative Medicine. As an alternative paradigm, past and recent history in Medical Science provides remarkable reverse stories in which clinical observations at the patient's bedside have fed major advances in basic research which, in turn, led to consistent progression in clinical practice. Within this context, we discuss our recently developed method and device, which forms the core of a system (Lipogems) for processing of human adipose tissue solely with the aid of mild mechanical forces to yield a microfractured tissue product.

Certified nurse-midwife and physician collaborative practice. Piloting a survey on the Internet.

PubMed

Miller, S; King, T; Lurie, P; Choitz, P

1997-01-01

This pilot study was designed to describe the clinical areas of collaboration, financial structures, and sources of conflict for certified nurse-midwives (CNMs) involved in nurse-midwife and physician collaborative practice (CP). A questionnaire was posted on an electronic bulletin board maintained by the Community-Based Nurse Midwifery Education Program of the Frontier School of Nursing. The nonrandom, convenience sample consisted of 78 respondents. Their mean age was 42 years; they had been in practice for a mean of 10 years, and 56% had graduate degrees. Eighty-nine percent reported involvement in CP. Eighty-three percent co-managed higher-risk women, and 46% performed vacuum-assisted deliveries or were first assistants at cesarean sections. Forty-eight percent of CNMs did not bill in their own names, and only 12% had full hospital privileges. The most common sources of conflict in CPs were clinical practice issues (100% ever encountered), power inequities (92%), financial issues (66%), and gender relations (58%). Collaborative practice is a common form of practice for CNMs and suggests a model for collaboration in other sectors of the health care system. Future research should explore methods of reducing the potential for conflict between CNMs and physicians.

Clinical education and clinical evaluation of respiratory therapy students.

PubMed

Cullen, Deborah L

2005-09-01

Different blends of knowledge, decision making, problem solving,professional behaviors, values, and technical skills are necessary in the changing health care environments in which respiratory therapists practice. Frequently, novice students are expected to perform quickly and efficiently,and it may be forgotten that students are still learning and mastering the foundation pieces of practice. Clinical educators take on the responsibility of student development in addition to overseeing patient care. Normally,these volunteer instructors are role models for respiratory therapy students. The characteristic of initiative when demonstrated by a beginning student is attractive to the clinical instructor, promotes sharing of experiences, and may evolve into a mentor-protege relationship. Some clinical instructors may be underprepared to teach and are uncomfortable with student evaluation. Respiratory therapy facilities in conjunction with academic institutions may consider sponsoring ongoing programs for clinical teachers. Teaching and learning in the clinical environment is more than demonstration of skills and knowledge. Furthermore, it can be debated whether the memorization of facts or of the steps of a skill is more valuable than competency in problem solving, clinical reasoning, or information retrieval. New knowledge is built within a context and is further integrated when grounded by experience. Development of "prediction in practice" or the anticipation of the next necessary actions may be worth integrating into the instructional toolbox. Intuition has been defined as an "understanding without a rationale". This definition separates intuition from rational decision making and presents intuition as a type of innate ability. Reflection when guided by clinical instructors can help deepen critical thinking, as will Socratic questioning on a regular basis. Most clinical staff can agree on the performance of an incompetent student, but discrimination of the levels of competence is more challenging. Observations allow the assessor to obtain the data necessary to evaluate performance, followed by assessment, which denotes a judgment made on the basis of an observation of events. Performance assessment should have stability and consistency, measure what is intended to be measured, and truly determine competence. In contrast, reflective analysis has been shown to be successful for clinical evaluation, thus departing from strict competency and product-based assessment. Students yearn to become clinically knowledgeable, and their enthusiasm should be fostered. An interest in clinical practice is the primary reason individuals enroll in respiratory therapy education programs. Educators,managers, and staff should assure that students experience an appropriate, rich, and diverse clinical curriculum that with practice develops clinical judgment, reasoning, and reflection on practice.

Clinical Practice Guidelines for the Management of Atopic Dermatitis 2016.

PubMed

Saeki, Hidehisa; Nakahara, Takeshi; Tanaka, Akio; Kabashima, Kenji; Sugaya, Makoto; Murota, Hiroyuki; Ebihara, Tamotsu; Kataoka, Yoko; Aihara, Michiko; Etoh, Takafumi; Katoh, Norito

2016-10-01

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. Most patients have an atopic predisposition. The definitive diagnosis of AD requires the presence of all three features: (i) pruritus; (ii) typical morphology and distribution of the eczema; and (iii) chronic and chronically relapsing course. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice. © 2016 Japanese Dermatological Association.

Training in multiple breath washout testing for respiratory physiotherapists.

PubMed

O'Neill, Katherine; Elborn, J Stuart; Tunney, Michael M; O'Neill, Philip; Rowan, Stephen; Martin, Susan; Bradley, Judy M

2018-03-01

The development of multiple breath washout (MBW) testing in respiratory disease highlights the need for increased awareness amongst respiratory physiotherapists and a potential opportunity for professional development in the use of an important outcome measure for clinical trials. To rationalise how MBW may be a useful assessment tool for respiratory physiotherapists and to describe a local MBW training and certification programme for physiotherapists. The respiratory Multidisciplinary Team in the Belfast Health and Social Care Trust (BHSCT) identified a need for MBW testing to be available to facilitate clinical research and assessment. A 2day training programme consisting of prereading preparation, self-directed learning, theory presentations, practical demonstrations and hands-on practice was developed and delivered. All participants underwent a certification process. We have demonstrated the successful training and certification of clinical and research physiotherapists and encourage other respiratory physiotherapists to consider MBW test training. Copyright © 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Evaluating online continuing medical education seminars: evidence for improving clinical practices.

PubMed

Weston, Christine M; Sciamanna, Christopher N; Nash, David B

2008-01-01

The purpose of this study was to evaluate the potential for online continuing medical education (CME) seminars to improve quality of care. Primary care physicians (113) participated in a randomized controlled trial to evaluate an online CME series. Physicians were randomized to view either a seminar about type 2 diabetes or a seminar about systolic heart failure. Following the seminar, physicians were presented with 4 clinical vignettes and asked to describe what tests, treatments, counseling, or referrals they would recommend. Physicians who viewed the seminars were significantly more likely to recommend guideline-consistent care to patients in the vignettes. For example, physicians who viewed the diabetes seminar were significantly more likely to order an eye exam for diabetes patients (63%) compared with physicians in the control group (27%). For some guidelines there were no group differences. These results provide early evidence of the effectiveness of online CME programs to improve physician clinical practice.

Principles and practice of external digital photography in ophthalmology

PubMed Central

Mukherjee, Bipasha; Nair, Akshay Gopinathan

2012-01-01

It is mandatory to incorporate clinical photography in an ophthalmic practice. Patient photographs are routinely used in teaching, presentations, documenting surgical outcomes and marketing. Standardized clinical photographs are part of an armamentarium for any ophthalmologist interested in enhancing his or her practice. Unfortunately, many clinicians still avoid taking patient photographs for want of basic knowledge or inclination. The ubiquitous presence of the digital camera and digital technology has made it extremely easy and affordable to take high-quality images. It is not compulsory to employ a professional photographer or invest in expensive equipment any longer for this purpose. Any ophthalmologist should be able to take clinical photographs in his/her office settings with minimal technical skill. The purpose of this article is to provide an ophthalmic surgeon with guidelines to achieve standardized photographic views for specific procedures, to achieve consistency, to help in pre-operative planning and to produce accurate pre-operative and post-operative comparisons, which will aid in self-improvement, patient education, medicolegal documentation and publications. This review also discusses editing, storage, patient consent, medicolegal issues and importance of maintenance of patient confidentiality. PMID:22446907

Variation in Protein Origin and Utilization: Research and Clinical Application.

PubMed

Paddon-Jones, Douglas; Coss-Bu, Jorge A; Morris, Claudia R; Phillips, Stuart M; Wernerman, Jan

2017-04-01

Muscle health can be rapidly compromised in clinical environments. Modifiable strategies to preserve metabolic homeostasis in adult patient populations include physical activity and pharmacologic support; however, optimizing dietary practices, or more specifically protein intake, is a necessary prerequisite for any other treatment strategy to be fully effective. Simply increasing protein intake is a well-intentioned but often unfocused strategy to protect muscle health in an intensive care setting. Protein quality is a frequently overlooked factor with the potential to differentially influence health outcomes. Quality can be assessed by a variety of techniques, with digestible indispensable amino acid score being the current and most comprehensive technique endorsed by the Food and Agriculture Organization. In practical terms, animal-based proteins are consistently scored higher in quality compared with incomplete proteins, regardless of the assessment method. Consequently, choosing parenteral and/or enteral feeding options that contain high-quality proteins, rich in the branched-chain amino acid leucine, may help establish a dietary framework with the potential to support clinical practice and improve health outcomes in critically ill patients.

Principles and practice of external digital photography in ophthalmology.

PubMed

Mukherjee, Bipasha; Nair, Akshay Gopinathan

2012-01-01

It is mandatory to incorporate clinical photography in an ophthalmic practice. Patient photographs are routinely used in teaching, presentations, documenting surgical outcomes and marketing. Standardized clinical photographs are part of an armamentarium for any ophthalmologist interested in enhancing his or her practice. Unfortunately, many clinicians still avoid taking patient photographs for want of basic knowledge or inclination. The ubiquitous presence of the digital camera and digital technology has made it extremely easy and affordable to take high-quality images. It is not compulsory to employ a professional photographer or invest in expensive equipment any longer for this purpose. Any ophthalmologist should be able to take clinical photographs in his/her office settings with minimal technical skill. The purpose of this article is to provide an ophthalmic surgeon with guidelines to achieve standardized photographic views for specific procedures, to achieve consistency, to help in pre-operative planning and to produce accurate pre-operative and post-operative comparisons, which will aid in self-improvement, patient education, medicolegal documentation and publications. This review also discusses editing, storage, patient consent, medicolegal issues and importance of maintenance of patient confidentiality.

[Factors influencing the quality of clinical practice guidelines in ovarian cancer].

PubMed

Castillo-Londoño, J S; Medina-Torres, Y A; Sandoval-Salinas, C; Buitrago-Gutierrez, G; Torres-Ibargüen, M Z; Gonzalez-Rangel, A L

To identify the characteristics of the published clinical practice guidelines for the management of epithelial ovarian cancer that suggest a good methodological quality. A literature review was performed on 25 clinical practice guidelines for epithelial ovarian cancer that were identified in different databases (MEDLINE, Guidelines International Network, National Guidelines Clearing house) published between 2007 and 2014. The quality of the guidelines was evaluated using the Appraisal of Guidelines Research and Evaluation II tool. Descriptive and bivariate analyses were performed to assess the association between the quality of the guidelines and of some of their features and their developers. Just under half (48%) of the guidelines were rated as low quality. Scientific societies or independent centres and private funding, or under-reporting the source of funding, were statistically associated with lower quality of clinical practice guidelines (P<.01). The guidelines developed by National Program Guidelines had a median of consistently higher scores in all domains of the Appraisal of Guidelines Research and Evaluation II, with significant differences in the definition of scope and objectives, the participation of stakeholders, the methodological rigour of development, and applicability to the context. Features such as the nature of the developer and funding of the guidelines are predictors of quality that should be taken into account prior to the use of the recommendations of a document. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Terms, concepts and definitions in clinical artificial nutrition. The ConT-SEEN Project.

PubMed

Del Olmo García, María Dolores; Ocón Bretón, Julia; Álvarez Hernández, Julia; Ballesteros Pomar, María Dolores; Botella Romero, Francisco; Bretón Lesmes, Irene; de Luis Román, Daniel; Luengo Pérez, Luis Miguel; Martínez Olmos, Miguel Ángel; Olveira Fuster, Gabriel

2018-01-01

Imprecision in terms used in the field of clinical nutrition may lead to misinterpretations among professionals. For this reason, the Spanish Society of Endocrinology and Nutrition (SEEN) promoted this document on the terms and definitions used in clinical artificial nutrition (enteral and parenteral), establishing an agreement between Spanish experts of this specialty. Forty-seven specialists in endocrinology and nutrition, members of the Nutrition Area of the SEEN, participated between April and September 2016. After a systematic literature review, 52 concepts were proposed. The coordinators included two additional concepts, and 57were finally selected by the working group: 13 of a general nature, 30 referring to enteral nutrition and 14 to parenteral nutrition. The degree of agreement was subsequently determined using a two-round Delphi process. It was finally ratified by consistency and concordance analysis. Fifty-four of the 57 terms had a very consistent agreement and were concordant. Only three showed no concordance, of whom two were very consistent and one inconsistent. In conclusion, there was consensus in the definition of 54 basic terms in the practice of clinical nutrition. Copyright © 2017 SEEN y SED. Publicado por Elsevier España, S.L.U. All rights reserved.

[Evidence-based medicine and 'The Cochrane Collaboration'].

PubMed

Kawamura, T; Tamakoshi, A; Wakai, K; Ohno, Y

1999-06-01

In Evidence-Based Medicine (EBM), a clinical decision is based neither on pathophysiological theories nor personal experience but on the results derived from scientifically designed clinical epidemiological studies (i.e., evidence). EBM is used in various clinical applications, such as therapy, diagnosis, and prognosis prediction. The process includes (1) asking a clinical question consisting of the three elements of "patient", "exposure", and "outcome"; (2) searching for the best evidence using MEDLINE or Cochrane Library; (3) appraising critically the validity of the method and the magnitude and probability of the result; and finally (4) applying the evidence of the patient. In actual clinical practice, clinical expertise and patient preferences should be as much regarded as research evidence. 'The Cochrane Collaboration' supplies systematic reviews of clinical trials carried out all over the world to its consumers. Its fruit, 'The Cochrane Library (CD-ROM),' is a highly valuable resource. 'The Cochrane Collaboration' serves as the infrastructure for EBM. EBM, which was originally developed for the individual patient care, can also be applicable to community- or workplace-healthcare and policy making by governments. Thus, EBM is both a philosophy and a method to provide people with the most appropriate medical practice.

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

PubMed

Porcino, Antony J; Boon, Heather S; Page, Stacey A; Verhoef, Marja J

2011-09-20

Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

Adults with ADHD Benefit from Cognitive-Behaviorally Oriented Group Rehabilitation: A Study of 29 Participants

ERIC Educational Resources Information Center

Virta, Maarit; Vedenpaa, Anita; Gronroos, Nina; Chydenius, Esa; Partinen, Markku; Vataja, Risto; Kaski, Markus; Iivanainen, Matti

2008-01-01

Objective: In clinical practice, a growing need exists for effective nonpharmacological treatments of adult ADHD. The authors present results from a cognitive-behaviorally oriented psychological group rehabilitation for adult ADHD. Method: A total of 29 adults with ADHD participated. Rehabilitation consisted of 10 or 11 weekly sessions.…

Psychosocial Risk Factors for Upper Respiratory Infections: Assessment of Upper Respiratory Illness during Basic Training

DTIC Science & Technology

1988-05-23

association was low enough to ensure that the URI composite was not merely an index of somatic stress reactions or hypochondriasis . The eight-item...report somatic symptoms in response to stress. Adjusted URI Severity also is consistent with the clinical practice of ruling out other possible types

Aphasia in Clinical Practice

PubMed Central

Kertesz, Andrew

1983-01-01

Aphasia is a central language impairment with word finding and comprehension deficit and paraphasias. The highlights of the essential language tests and the classification based on a scorable assessment are presented. The clinical syndromes of Broca's, global, Wernicke, conduction, anomic and transcortical aphasias are detailed with definition, localization, and prognosis. Modality specific disorders associated with aphasic syndromes are discussed. The management of the aphasic patient, consisting of informed support and coordination of available services, is often the responsibility of the family physician. ImagesFig. 1Fig. 2 PMID:21286589

How to Prepare a Patient for Transarterial Radioembolization? A Practical Guide.

PubMed

Denys, Alban; Pracht, Marc; Duran, Rafael; Guiu, Boris; Adib, Salim; Boubaker, Ariane; Bize, Pierre

2015-08-01

Transarterial radioembolization consist in delivering small particles loaded with Yttrium90, a pure beta emitter, in order to treat primary and secondary liver tumors. This treatment needs precaution since inadequate delivery of these beads can lead to severe complications. Moreover, a precise radiation dosing is crucial to achieve a good clinical success and to avoid complications such as radioembolization-induced liver disease. This review describes all the precautions and highlights clinical and technical considerations that need to be taken to avoid complications.

Clinic Workload, the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients.

PubMed

Vargas Bustamante, Arturo; Martinez, Ana; Chen, Xiao; Rodriguez, Hector P

2017-06-01

We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.

Quantitative Stratification of Diffuse Parenchymal Lung Diseases

PubMed Central

Raghunath, Sushravya; Rajagopalan, Srinivasan; Karwoski, Ronald A.; Maldonado, Fabien; Peikert, Tobias; Moua, Teng; Ryu, Jay H.; Bartholmai, Brian J.; Robb, Richard A.

2014-01-01

Diffuse parenchymal lung diseases (DPLDs) are characterized by widespread pathological changes within the pulmonary tissue that impair the elasticity and gas exchange properties of the lungs. Clinical-radiological diagnosis of these diseases remains challenging and their clinical course is characterized by variable disease progression. These challenges have hindered the introduction of robust objective biomarkers for patient-specific prediction based on specific phenotypes in clinical practice for patients with DPLD. Therefore, strategies facilitating individualized clinical management, staging and identification of specific phenotypes linked to clinical disease outcomes or therapeutic responses are urgently needed. A classification schema consistently reflecting the radiological, clinical (lung function and clinical outcomes) and pathological features of a disease represents a critical need in modern pulmonary medicine. Herein, we report a quantitative stratification paradigm to identify subsets of DPLD patients with characteristic radiologic patterns in an unsupervised manner and demonstrate significant correlation of these self-organized disease groups with clinically accepted surrogate endpoints. The proposed consistent and reproducible technique could potentially transform diagnostic staging, clinical management and prognostication of DPLD patients as well as facilitate patient selection for clinical trials beyond the ability of current radiological tools. In addition, the sequential quantitative stratification of the type and extent of parenchymal process may allow standardized and objective monitoring of disease, early assessment of treatment response and mortality prediction for DPLD patients. PMID:24676019

Harmonization of blood-based indicators of iron status: making the hard work matter.

PubMed

Hoofnagle, Andrew N

2017-12-01

Blood-based indicators that are used in the assessment of iron status are assumed to be accurate. In practice, inaccuracies in these measurements exist and stem from bias and variability. For example, the analytic variability of serum ferritin measurements across laboratories is very high (>15%), which increases the rate of misclassification in clinical and epidemiologic studies. The procedures that are used in laboratory medicine to minimize bias and variability could be used effectively in clinical research studies, particularly in the evaluation of iron deficiency and its associated anemia in pregnancy and early childhood and in characterizing states of iron repletion and excess. The harmonization and standardization of traditional and novel bioindicators of iron status will allow results from clinical studies to be more meaningfully translated into clinical practice by providing a firm foundation for clinical laboratories to set appropriate cutoffs. In addition, proficiency testing monitors the performance of the methods over time. It is important that measures of iron status be evaluated, validated, and performed in a manner that is consistent with standard procedures in laboratory medicine. © 2017 American Society for Nutrition.

Improving family medicine resident training in dementia care: an experiential learning opportunity in Primary Care Collaborative Memory Clinics.

PubMed

Lee, Linda; Weston, W Wayne; Hillier, Loretta; Archibald, Douglas; Lee, Joseph

2018-06-21

Family physicians often find themselves inadequately prepared to manage dementia. This article describes the curriculum for a resident training intervention in Primary Care Collaborative Memory Clinics (PCCMC), outlines its underlying educational principles, and examines its impact on residents' ability to provide dementia care. PCCMCs are family physician-led interprofessional clinic teams that provide evidence-informed comprehensive assessment and management of memory concerns. Within PCCMCs residents learn to apply a structured approach to assessment, diagnosis, and management; training consists of a tutorial covering various topics related to dementia followed by work-based learning within the clinic. Significantly more residents who trained in PCCMCs (sample = 98), as compared to those in usual training programs (sample = 35), reported positive changes in knowledge, ability, and confidence in ability to assess and manage memory problems. The PCCMC training intervention for family medicine residents provides a significant opportunity for residents to learn about best clinical practices and interprofessional care needed for optimal dementia care integrated within primary care practice.

Evidence-based decision-making as a practice-based learning skill: a pilot study.

PubMed

Falzer, Paul R; Garman, D Melissa

2012-03-01

As physicians are being trained to adapt their practices to the needs and experience of patients, initiatives to standardize care have been gaining momentum. The resulting conflict can be addressed through a practice-based learning and improvement (PBL) program that develops competency in using treatment guidelines as decision aids and incorporating patient-specific information into treatment recommendations. This article describes and tests a program that is consistent with the ACGME's multilevel competency-based approach, targets students at four levels of training, and features progressive learning objectives and assessments. The program was pilot-tested with 22 paid volunteer psychiatric residents and fellows. They were introduced to a schizophrenia treatment guideline and reviewed six case vignettes of varying complexity. PBL assessments were based on how treatment recommendations were influenced by clinical and patient-specific factors. The task permitted separate assessments of learning objectives all four training levels. Among the key findings at each level, most participants found the treatment guideline helpful in making treatment decisions. Recommendations were influenced by guideline-based assessment criteria and other clinical features. They were also influenced by patients' perceptions of their illness, patient-based progress assessments, and complications such as stressors and coping patterns. Recommendations were strongly influenced by incongruence between clinical facts and patient experience. Practical understanding of how patient experience joins with clinical knowledge can enhance the use of treatment guidelines as decision tools and enable clinicians to appreciate more fully how and why patients' perceptions of their illness should influence treatment recommendations. This PBL program can assist training facilities in preparing students to cope with contradictory demands to both standardize and adapt their practice. The program can be modified to accommodate various disorders and a range of clinical factors and patient-specific complications.

Information and Communication Technologies for the Dissemination of Clinical Practice Guidelines to Health Professionals: A Systematic Review.

PubMed

De Angelis, Gino; Davies, Barbara; King, Judy; McEwan, Jessica; Cavallo, Sabrina; Loew, Laurianne; Wells, George A; Brosseau, Lucie

2016-11-30

The transfer of research knowledge into clinical practice can be a continuous challenge for researchers. Information and communication technologies, such as websites and email, have emerged as popular tools for the dissemination of evidence to health professionals. The objective of this systematic review was to identify research on health professionals' perceived usability and practice behavior change of information and communication technologies for the dissemination of clinical practice guidelines. We used a systematic approach to retrieve and extract data about relevant studies. We identified 2248 citations, of which 21 studies met criteria for inclusion; 20 studies were randomized controlled trials, and 1 was a controlled clinical trial. The following information and communication technologies were evaluated: websites (5 studies), computer software (3 studies), Web-based workshops (2 studies), computerized decision support systems (2 studies), electronic educational game (1 study), email (2 studies), and multifaceted interventions that consisted of at least one information and communication technology component (6 studies). Website studies demonstrated significant improvements in perceived usefulness and perceived ease of use, but not for knowledge, reducing barriers, and intention to use clinical practice guidelines. Computer software studies demonstrated significant improvements in perceived usefulness, but not for knowledge and skills. Web-based workshop and email studies demonstrated significant improvements in knowledge, perceived usefulness, and skills. An electronic educational game intervention demonstrated a significant improvement from baseline in knowledge after 12 and 24 weeks. Computerized decision support system studies demonstrated variable findings for improvement in skills. Multifaceted interventions demonstrated significant improvements in beliefs about capabilities, perceived usefulness, and intention to use clinical practice guidelines, but variable findings for improvements in skills. Most multifaceted studies demonstrated significant improvements in knowledge. The findings suggest that health professionals' perceived usability and practice behavior change vary by type of information and communication technology. Heterogeneity and the paucity of properly conducted studies did not allow for a clear comparison between studies and a conclusion on the effectiveness of information and communication technologies as a knowledge translation strategy for the dissemination of clinical practice guidelines. ©Gino De Angelis, Barbara Davies, Judy King, Jessica McEwan, Sabrina Cavallo, Laurianne Loew, George A Wells, Lucie Brosseau. Originally published in JMIR Medical Education (http://mededu.jmir.org), 30.11.2016.

Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases.

PubMed

Skipper, Annalynn

2012-02-01

Nutrition support clinicians refer to the abnormalities in laboratory data and changes in clinical signs and symptoms that follow refeeding of starved or malnourished patients as refeeding syndrome. Theoretical descriptions of refeeding syndrome include a complex and extensive list of changes, such as hypophosphatemia, hypomagnesemia, hypokalemia, hyponatremia, hypocalcemia, hyperglycemia, and vitamin deficiency--all of which are accompanied by clinical signs and symptoms. In practice, clinicians see asymptomatic refeeding hypophosphatemia more often than a full-blown syndrome with multiple laboratory and clinical abnormalities. Confusion results because there is no widely accepted or uniformly applied set of defining characteristics for diagnosing refeeding syndrome. To gain insight into the clinical characteristics of refeeding syndrome described in the literature, a systematic review of reported cases and case series was conducted. Since 2000, 20 authors described 27 cases that contained sufficient data for review. Hypophosphatemia occurred in 26 patients (96%). While 19 patients (71%) experienced at least 1 other laboratory abnormality, only 14 (51%) exhibited a consistent pattern of abnormally low phosphorus and magnesium levels. Seven patients had hypocalcemia (26%), and hyponatremia was reported in 3 patients (11%). There were no reports of hyperglycemia. Mean data reported in case series containing data from 63 patients showed that hypophosphatemia was a consistent finding but that other abnormalities were not consistently identified. Findings suggest that refeeding hypophosphatemia is not accompanied by a consistent pattern of biochemical or clinical abnormalities among case reports or case series of patients reported to have refeeding syndrome.

Sponsor-Imposed Publication Restrictions Disclosed on ClinicalTrials.gov.

PubMed

Stretton, Serina; Lew, Rebecca A; Ely, Julie A; Snape, Mark J; Carey, Luke C; Haley, Cassandra; Woolley, Mark J; Woolley, Karen L

2016-01-01

We investigated whether sponsor-imposed publication restrictions for ClinicalTrials.gov trials were reasonable, based on consistency with Good Publication Practice 2 (GPP2). ClinicalTrials.gov trial record data were electronically imported (October 7, 2012) and screened for eligibility (phase 2-4, interventional, recruitment closed, results available, first received for registration after November 10, 2009, any sponsor type, investigators not sponsor employees). Two authors categorized restrictions information as consistent or not consistent with GPP2, resolving discrepancies by consensus. Of the eligible trials (388/484, n = 81,768 participants), 80.7% (313/388) had restrictions disclosed, and 92.5% (311/388) were industry-sponsored. Significantly more trials had restrictions that were consistent with GPP2 than not (74.1% [232/313], n = 55,280 participants vs. 25.9% [81/313], n = 19,677 participants; P < .001). Reasons for inconsistency were insufficient, unclear, or ambiguous information (48.1%, 39/81), sponsor-required approval for publication (35.8%, 29/81), sponsor-required text changes (8.6%, 7/81), and outright bans (7.4%, 6/81). Follow-up of trials with insufficient information and a contact email (response rate, 46.9% [15/32]) revealed 2 additional bans. A total of 776 participants had consented to trials that had publication bans. Many, but not all, sponsor-imposed publication restrictions disclosed on ClinicalTrials.gov may be considered reasonable. Sponsors should ensure restrictions are appropriately disclosed. Volunteers should be alerted to any restrictions before consenting to participate in a clinical trial.

Returning nurses to the workforce: developing a fast track back program.

PubMed

Burns, Helen K; Sakraida, Teresa J; Englert, Nadine C; Hoffmann, Rosemary L; Tuite, Patricia; Foley, Susan M

2006-01-01

Fast Track Back: Re-entry into Nursing Practice program. Describes the development, implementation, and evaluation of a state-of-the-art re-entry program facilitating the return of licensed nonpracticing RNs to the workforce through a quality education program that retools them for the workforce in the areas of pharmacology, skill development using the latest technology, practice standards, and nursing issues. The program consists of didactic content taught via classroom, Internet, skills laboratory, and high fidelity human simulated technology and a clinical component. The program is a mechanism that enables re-entry nurses to improve skills and competencies necessary to practice in today's healthcare environment.

Implementation of Patient Decision Support Interventions in Primary Care: The Role of Relational Coordination.

PubMed

Tietbohl, Caroline K; Rendle, Katharine A S; Halley, Meghan C; May, Suepattra G; Lin, Grace A; Frosch, Dominick L

2015-11-01

The benefits of patient decision support interventions (DESIs) have been well documented. However, DESIs remain difficult to incorporate into clinical practice. Relational coordination (RC) has been shown to improve performance and quality of care in health care settings. This study aims to demonstrate how applying RC theory to DESI implementation could elucidate underlying issues limiting widespread uptake. Five primary care clinics in Northern California participated in a DESI implementation project. We used a deductive thematic approach guided by behaviors outlined in RC theory to analyze qualitative data collected from ethnographic field notes documenting the implementation process and focus groups with health care professionals. We then systematically compared the qualitative findings with quantitative DESI distribution data. Based on DESI distribution rates, clinics were placed into 3 performance categories: high, middle, and low. Qualitative data illustrated how each clinic's performance related to RC behaviors. Consistent with RC theory, the high-performing clinic exhibited frequent, timely, and accurate communication and positive working relationships. The 3 middle-performing clinics exhibited high-quality communication within physician-staff teams but limited communication regarding DESI implementation across the clinic. The lowest-performing clinic was characterized by contentious relationships and inadequate communication. Limitations of the study include nonrandom selection of clinics and limited geographic diversity. In addition, ethnographic data collected documented only DESI implementation practices and not larger staff interactions contributing to RC. These findings suggest that a high level of RC within clinical settings may be a key component and facilitator of successful DESI implementation. Future attempts to integrate DESIs into clinical practice should consider incorporating interventions designed to increase positive RC behaviors as a potential means to improve uptake. © The Author(s) 2015.

Implementing community-based provider participation in research: an empirical study

PubMed Central

2012-01-01

Background Since 2003, the United States National Institutes of Health (NIH) has sought to restructure the clinical research enterprise in the United States by promoting collaborative research partnerships between academically-based investigators and community-based physicians. By increasing community-based provider participation in research (CBPPR), the NIH seeks to advance the science of discovery by conducting research in clinical settings where most people get their care, and accelerate the translation of research results into everyday clinical practice. Although CBPPR is seen as a promising strategy for promoting the use of evidence-based clinical services in community practice settings, few empirical studies have examined the organizational factors that facilitate or hinder the implementation of CBPPR. The purpose of this study is to explore the organizational start-up and early implementation of CBPPR in community-based practice. Methods We used longitudinal, case study research methods and an organizational model of innovation implementation to theoretically guide our study. Our sample consisted of three community practice settings that recently joined the National Cancer Institute’s (NCI) Community Clinical Oncology Program (CCOP) in the United States. Data were gathered through site visits, telephone interviews, and archival documents from January 2008 to May 2011. Results The organizational model for innovation implementation was useful in identifying and investigating the organizational factors influencing start-up and early implementation of CBPPR in CCOP organizations. In general, the three CCOP organizations varied in the extent to which they achieved consistency in CBPPR over time and across physicians. All three CCOP organizations demonstrated mixed levels of organizational readiness for change. Hospital management support and resource availability were limited across CCOP organizations early on, although they improved in one CCOP organization. As a result of weak IPPs, all three CCOPs created a weak implementation climate. Patient accrual became concentrated over time among those groups of physicians for whom CBPPR exhibited a strong innovation-values fit. Several external factors influenced innovation use, complicating and enriching our intra-organizational model of innovation implementation. Conclusion Our results contribute to the limited body of research on the implementation of CBPPR. They inform policy discussions about increasing and sustaining community clinician involvement in clinical research and expand on theory about organizational determinants of implementation effectiveness. PMID:22568935

Blood transfusion practice in the UK and Ireland: a survey of palliative care physicians.

PubMed

Neoh, Karen; Stanworth, Simon; Bennett, Michael I

2018-03-23

Red cell (blood) transfusions are used in palliative care to manage patients with symptomatic anaemia or when patients have lost blood. We aimed to understand current blood transfusion practice among palliative medicine doctors and compare this with National Institute for Health and Care Excellence (NICE) guidance. NICE guidance advocates more restrictive transfusion practice but is based on clinical trials in non-palliative care contexts; the extent to which these findings should be applied to palliative care remains unclear. Four clinical vignettes of common clinical palliative care scenarios were developed. Members of the Association for Palliative Medicine were invited to complete the survey. Results were compared with acceptable responses based on current NICE recommendations and analysed to determine the influence of respondents' gender, experience or work setting. 27% of 1070 members responded. Overall, ideal or acceptable responses were selected by less than half of doctors to all four vignettes. Doctors were more liberal in prescribing blood transfusions than NICE guidance would advocate. Senior doctors were less likely to choose an acceptable response than junior colleagues. Palliative care practice is varied and not consistent with a restrictive blood transfusion policy. More recently trained doctors follow less liberal practices than senior colleagues. More direct evidence of benefits and harms of blood transfusion is needed in palliative care to inform practice. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines.

PubMed

Malhi, Gin S; Gessler, Danielle; Outhred, Tim

2017-08-01

Lithium is an effective mood stabilizer that is used principally for the management of bipolar disorder (BD). Its administration is complex and often requires sophisticated management and assiduous monitoring. When considering the use of lithium therapy for bipolar disorder, clinicians are advised to refer to recommendations outlined in clinical practice guidelines (CPGs); but because of varying emphases placed by different international CPGs, recommendations addressing the practical use of lithium lack consistency. In order to inform clinicians of optimal lithium therapy for bipolar disorder, we compared and synthesized recommendations for the treatment of bipolar disorder made by recognized CPGs internationally. We conducted a search of the literature and extracted guidance across multiple clinical issues, including clinical indications, disorder subtypes, additional uses, special populations, practical aspects, and side effects. Collectively, CPGs consider lithium most robustly as a first-line intervention for maintenance treatment of bipolar disorder and strongly for the treatment of mania, with relatively modest support for the management of acute bipolar depression. Additionally, there is consensus across the CPGs that lithium tangibly reduces the risk of suicide. Generally, CPGs provide guidance on the many facets of initiating and maintaining patients on lithium therapy, but individually the CPGs varied in terms of depth and practical guidance they provide across these areas. However, consensus was established across many key areas of practice such as the ideal lithium plasma concentration for maintenance and monitoring (0.6-0.8mmol/L), along with the need for regular monitoring of renal and endocrine function. However, with more complex aspects (e.g., atypical presentations) and in special populations (e.g., youth; pregnancy and post-partum; older adults), guidance varied considerably and clear consensus recommendations were more difficult to achieve. In younger adults desirable plasma lithium levels of 0.6-0.8mmol/L can perhaps be achieved with comparatively lower doses and in the very elderly it may be prudent to target lower plasma levels in the first instance. These are important practical points for consideration that, along with many others offered throughout the article, should assist clinicians in dissecting the more complex aspects of management with greater precision. This review was limited to CPGs written in English. CPGs are themselves limited by reliance on evidence that often has little resemblance to real-world presentations. An important area that is not sufficiently addressed in the CPGs is clear guidance on the cessation of lithium therapy. Further research is needed on many aspects of lithium therapy and this alongside existing knowledge needs to be used more consistently to inform CPGs, which should also incorporate empirical evidence and clinical experience. The recommendations in this paper provide a useful synthesis of guidance available currently. Copyright © 2017 Elsevier B.V. All rights reserved.

Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial.

PubMed

French, Simon D; McKenzie, Joanne E; O'Connor, Denise A; Grimshaw, Jeremy M; Mortimer, Duncan; Francis, Jill J; Michie, Susan; Spike, Neil; Schattner, Peter; Kent, Peter; Buchbinder, Rachelle; Page, Matthew J; Green, Sally E

2013-01-01

This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. Australian New Zealand Clinical Trials Registry ACTRN012606000098538.

Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial

PubMed Central

French, Simon D.; McKenzie, Joanne E.; O'Connor, Denise A.; Grimshaw, Jeremy M.; Mortimer, Duncan; Francis, Jill J.; Michie, Susan; Spike, Neil; Schattner, Peter; Kent, Peter; Buchbinder, Rachelle; Page, Matthew J.; Green, Sally E.

2013-01-01

Introduction This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. Methods General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. Results 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN012606000098538 PMID:23785427

Sickness certification of patients--a work environment problem among physicians?

PubMed

Ljungquist, T; Hinas, E; Arrelöv, B; Lindholm, C; Wilteus, A L; Nilsson, G H; Alexanderson, K

2013-01-01

According to several studies, physicians find sickness certification of patients to be problematic, and some smaller studies suggest that this is a psychosocial work environment problem (WEP). To explore to what extent physicians experience sickness certification as a WEP and the associations of this with the type of clinic and other workplace factors. Analyses of data from a questionnaire sent to all physicians who were living and working in Sweden. The study group consisted of physicians aged <65 years who performed sickness certification tasks (SCTs). Prevalence rates (PR) and 95% confidence intervals (CI) of finding SCTs as a WEP in relation to background factors were calculated. The response rate was 61%. The final study group consisted of 14 210 responders. Half of the physicians (50%) experienced SCTs as a WEP, and 11% found them as a WEP to a great extent. The proportion of physicians experiencing certification tasks as a WEP varied with the type of clinic and were highest in general practice (73%), orthopaedics (68%), rheumatology (67%), neurology (59%) and psychiatry (58%). Using internal medicine as a reference group, the PRs for finding SCTs as a WEP to a great extent were 4.05 (95% CI 3.23-5.09) in general practice, 2.67 (2.05-3.47) in psychiatry and 2.66 (2.04-3.47) in orthopaedics, after adjusting for educational level and frequency of sickness certification consultations. In ear, nose and throat clinics, the PR was 0.43 (0.21-0.88). The findings underline the importance of measures to improve the work situation for physicians regarding sickness certification practices.

Tailored weight loss intervention in obese adults within primary care practice: rationale, design, and methods of Choose to Lose.

PubMed

Hartman, Sheri J; Risica, Patricia M; Gans, Kim M; Marcus, Bess H; Eaton, Charles B

2014-07-01

Although there are efficacious weight loss interventions that can improve health and delay onset of diabetes and hypertension, these interventions have not been translated into clinical practice. The primary objective of this study is to evaluate the effectiveness and cost effectiveness of a tailored lifestyle intervention in primary care patients. Patients were recruited by their primary care physicians and eligible participants were randomized to an enhanced intervention or standard intervention. All participants met with a lifestyle counselor to set calorie and physical activity goals and to discuss behavioral strategies at baseline, 6 and 12 months. During the first year, enhanced intervention participants receive monthly counseling phone calls to assist in attaining and maintaining their goals. Enhanced intervention participants also receive weekly mailings consisting of tailored and non-tailored print materials and videos focusing on weight loss, physical activity promotion and healthy eating. The second year focuses on maintenance with enhanced intervention participants receiving tailored and non-tailored print materials and videos regularly throughout the year. Standard intervention participants receive five informational handouts on weight loss across the two years. This enhanced intervention that consists of multiple modalities of print, telephone, and video with limited face-to-face counseling holds promise for being effective for encouraging weight loss, increasing physical activity and healthy eating, and also for being cost effective and generalizable for wide clinical use. This study will fill an important gap in our knowledge regarding the translation and dissemination of research from efficacy studies to best practices in clinical settings. Copyright © 2014 Elsevier Inc. All rights reserved.

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care

PubMed Central

Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M.

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices. PMID:28752808

Just-in-Time Evidence-Based E-mail “Reminders” in Home Health Care: Impact on Nurse Practices

PubMed Central

Murtaugh, Christopher M; Pezzin, Liliana E; McDonald, Margaret V; Feldman, Penny H; Peng, Timothy R

2005-01-01

Objective To test the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses caring for heart failure (HF) patients. Data Sources/Study Setting Information on nurse practices was abstracted from the clinical records of patients admitted between June 2000 and November 2001 to the care of 354 study nurses at a large, urban, nonprofit home care agency. Study Design The study employed a randomized design with nurses assigned to usual care or one of two intervention groups upon identification of an eligible patient. The basic intervention was a one-time e-mail reminder highlighting six HF-specific clinical recommendations. The augmented intervention consisted of the initial e-mail reminder supplemented by provider prompts, patient education material, and clinical nurse specialist outreach. Data Collection At each home health visit provided by a study nurse to an eligible HF patient during the 45-day follow-up period, a structured chart abstraction tool was used to collect information on whether the nurse provided the care practices highlighted in the e-mail reminder. Principal Findings Both the basic and the augmented interventions greatly increased the practice of evidence-based care, according to patient records, in the areas of patient assessment and instructions about HF disease management. While not all results were statistically significant at conventional levels, intervention effects were positive in virtually all cases and effect magnitudes frequently were large. Conclusions The results of this randomized trial strongly support the efficacy of just-in-time evidence-based reminders as a means of changing clinical practice among home health nurses who are geographically dispersed and spend much of their time in the field. PMID:15960694

The journey of primary care practices to meaningful use: a Colorado Beacon Consortium study.

PubMed

Fernald, Douglas H; Wearner, Robyn; Dickinson, W Perry

2013-01-01

The Health Information Technology for Economic and Clinical Health Act of 2009 provides for incentive payments through Medicare and Medicaid for clinicians who implement electronic health records (EHRs) and use this technology meaningfully to improve patient care. There are few comprehensive descriptions of how primary care practices achieve the meaningful use of clinical data, including the formal stage 1 meaningful use requirements. Evaluation of the Colorado Beacon Consortium project included iterative qualitative analysis of practice narratives, provider and staff interviews, and separate focus groups with quality improvement (QI) advisors and staff from the regional health information exchange (HIE). Most practices described significant realignment of practice priorities and aims, which often required substantial education and training of physicians and staff. Re-engineering office processes, data collection protocols, EHRs, staff roles, and practice culture comprised the primary effort and commitment to attest to stage 1 meaningful use and subsequent meaningful use of clinical data. While realizing important benefits, practices bore a significant burden in learning the true capabilities of their EHRs with little effective support from vendors. Attestation was an important initial milestone in the process, but practices faced substantial ongoing work to use their data meaningfully for patient care and QI. Key resources were instrumental to these practices: local technical EHR expertise; collaborative learning mechanisms; and regular contact and support from QI advisors. Meeting the stage 1 requirements for incentives under Medicare and Medicaid meaningful use criteria is the first waypoint in a longer journey by primary care practices to the meaningful use of electronic data to continuously improve the care and health of their patients. The intensive re-engineering effort for stage 1 yielded practice changes consistent with larger practice aims and goals. While many of these practices are now poised to use data meaningfully, faster progress will likely come with continued local QI and technical support and planned community-wide learning.

Impact of a dedicated cancer-associated thrombosis service on clinical outcomes: a mixed-methods evaluation of a clinical improvement exercise.

PubMed

Noble, Simon; Pease, Nikki; Sui, Jessica; Davies, James; Lewis, Sarah; Malik, Usman; Alikhan, Raza; Prout, Hayley; Nelson, Annmarie

2016-11-28

Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation. Specialist cancer centre, district general hospital and primary care. Patients with CAT and their referring clinicians. A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic. The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals. Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management. A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Clinimetrics: the science of clinical measurements.

PubMed

Fava, G A; Tomba, E; Sonino, N

2012-01-01

'Clinimetrics' is the term introduced by Alvan R. Feinstein in the early 1980s to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs and other clinical phenomena. Clinimetrics has a set of rules that govern the structure of indexes, the choice of component variables, the evaluation of consistency, validity and responsiveness. This review illustrates how clinimetrics may help expanding the narrow range of information that is currently used in clinical science. It will focus on characteristics and types of clinimetric indexes and their current use. The clinimetric perspective provides an intellectual home for clinical judgment, whose implementation is likely to improve outcomes both in clinical research and practice. © 2011 Blackwell Publishing Ltd.

Imbalanced target prediction with pattern discovery on clinical data repositories.

PubMed

Chan, Tak-Ming; Li, Yuxi; Chiau, Choo-Chiap; Zhu, Jane; Jiang, Jie; Huo, Yong

2017-04-20

Clinical data repositories (CDR) have great potential to improve outcome prediction and risk modeling. However, most clinical studies require careful study design, dedicated data collection efforts, and sophisticated modeling techniques before a hypothesis can be tested. We aim to bridge this gap, so that clinical domain users can perform first-hand prediction on existing repository data without complicated handling, and obtain insightful patterns of imbalanced targets for a formal study before it is conducted. We specifically target for interpretability for domain users where the model can be conveniently explained and applied in clinical practice. We propose an interpretable pattern model which is noise (missing) tolerant for practice data. To address the challenge of imbalanced targets of interest in clinical research, e.g., deaths less than a few percent, the geometric mean of sensitivity and specificity (G-mean) optimization criterion is employed, with which a simple but effective heuristic algorithm is developed. We compared pattern discovery to clinically interpretable methods on two retrospective clinical datasets. They contain 14.9% deaths in 1 year in the thoracic dataset and 9.1% deaths in the cardiac dataset, respectively. In spite of the imbalance challenge shown on other methods, pattern discovery consistently shows competitive cross-validated prediction performance. Compared to logistic regression, Naïve Bayes, and decision tree, pattern discovery achieves statistically significant (p-values < 0.01, Wilcoxon signed rank test) favorable averaged testing G-means and F1-scores (harmonic mean of precision and sensitivity). Without requiring sophisticated technical processing of data and tweaking, the prediction performance of pattern discovery is consistently comparable to the best achievable performance. Pattern discovery has demonstrated to be robust and valuable for target prediction on existing clinical data repositories with imbalance and noise. The prediction results and interpretable patterns can provide insights in an agile and inexpensive way for the potential formal studies.

[Role of medical information processing for quality assurance in obstetrics].

PubMed

Selbmann, H K

1983-06-01

The paradigma of problem-orientated assuring of the professional quality of medical case is a kind of "control loop system" consisting of the following 5 steps: routine observation, identification of the problem, analysis of the problem, translation of problem solutions into daily practice and control as to whether the problem has been solved or eliminated. Medical data processing, which involves documentation, electronic data processing and statistics, can make substantial contributions especially to the steps of observation, identification of the problem, and follow-up control. Perinatal data collection, which has already been introduced in 6 Länder of the Federal Republic of Germany, has supplied ample proof of this. These operations were conducted under the heading "internal clinical assuring of quality with external aid". Those clinics who participated in this programme, were given the necessary aid in self-observation (questionnaires, clinical statistics), and they were also given comparative informative data to help them in identifying the problems (clinical profiles, etc.). It is entirely left to the responsibility of the clinics themselves--voluntary cooperation and guarantee of remaining anonymous being a matter of course -- to draw their own consequences from the collected data and to translate these into clinical everyday practice.

Data Safe Havens and Trust: Toward a Common Understanding of Trusted Research Platforms for Governing Secure and Ethical Health Research

PubMed Central

Nicholls, Jacqueline; Dobbs, Christine; Sethi, Nayha; Cunningham, James; Ainsworth, John; Heaven, Martin; Peacock, Trevor; Peacock, Anthony; Jones, Kerina; Laurie, Graeme; Kalra, Dipak

2016-01-01

In parallel with the advances in big data-driven clinical research, the data safe haven concept has evolved over the last decade. It has led to the development of a framework to support the secure handling of health care information used for clinical research that balances compliance with legal and regulatory controls and ethical requirements while engaging with the public as a partner in its governance. We describe the evolution of 4 separately developed clinical research platforms into services throughout the United Kingdom-wide Farr Institute and their common deployment features in practice. The Farr Institute is a case study from which we propose a common definition of data safe havens as trusted platforms for clinical academic research. We use this common definition to discuss the challenges and dilemmas faced by the clinical academic research community, to help promote a consistent understanding of them and how they might best be handled in practice. We conclude by questioning whether the common definition represents a safe and trustworthy model for conducting clinical research that can stand the test of time and ongoing technical advances while paying heed to evolving public and professional concerns. PMID:27329087

Home Care Pharmacy Practice in Canada: A Cross-Sectional Survey of Services Provided, Remuneration, Barriers, and Facilitators.

PubMed

Houle, Sherilyn; MacKeigan, Linda

2017-01-01

As the population ages, and individuals desire to remain in their homes as long as possible, the need for in-home care is expected to increase. However, pharmacists have rarely been included in studies of in-home care, and little is known about the prevalence or effectiveness of pharmacists' home-based services in Canada. To identify pharmacy practices in Canada that regularly provide in-home patient care and to identify specific services provided, remuneration obtained, and barriers and facilitators influencing the provision of home-based care. A link to a web-based survey was posted in e-newsletters of provincial, territorial, and national pharmacy associations in Canada. In addition, pharmacists known to the researchers as providing in-home clinical services were contacted directly. The survey was open from October to December 2015. Practices or organizations that performed at least one home visit per week for clinical purposes, with documentation of the services provided, were eligible to participate. One response per practice or organization was allowed. Seventeen practices meeting the inclusion criteria were identified, representing community, hospital, and clinic settings. Home visits were most commonly performed for individuals with complex medication regimens or nonadherence to medication therapy. The most common services were conducting medication reconciliation and reviews and counselling patients about medication adherence. No practices or organizations billed patients for these services, yet lack of remuneration was an important barrier identified by many respondents. Although 12 (71%) of the respondents collected data for evaluative purposes, collection of clinical or health system outcome data was rare. Few Canadian pharmacy practices that provide in-home patient care at least once a week could be identified. Data collection suitable to establish an evidence base for this service was infrequently performed by practices and organizations providing home-based care. Such evidence is needed to justify the expansion of this service nationally, including consistent and adequate remuneration from governments or other payers.

Clinical teaching based on principles of cognitive apprenticeship: views of experienced clinical teachers.

PubMed

Stalmeijer, Renée E; Dolmans, Diana H J M; Snellen-Balendong, Hetty A M; van Santen-Hoeufft, Marijke; Wolfhagen, Ineke H A P; Scherpbier, Albert J J A

2013-06-01

To explore (1) whether an instructional model based on principles of cognitive apprenticeship fits with the practice of experienced clinical teachers and (2) which factors influence clinical teaching during clerkships from an environmental, teacher, and student level as perceived by the clinical teachers themselves. The model was designed to apply directly to teaching behaviors of clinical teachers and consists of three phases, advocating teaching behaviors such as modeling, creating a safe learning environment, coaching, knowledge articulation, and exploration. A purposive sample of 17 experienced clinical teachers from five different disciplines and four different teaching hospitals took part in semistructured individual interviews. Two researchers independently performed a thematic analysis of the interview transcripts. Coding was discussed within the research team until consensus was reached. All participants recognized the theoretical model as a structured picture of the practice of teaching activities during both regular and senior clerkships. According to participants, modeling and creating a safe learning environment were fundamental to the learning process of both regular and senior clerkship students. Division of teaching responsibilities, longer rotations, and proactive behavior of teachers and students ensured that teachers were able to apply all steps in the model. The theoretical model can offer valuable guidance in structuring clinical teaching activities and offers suggestions for the design of effective clerkships.

How many research nurses for how many clinical trials in an oncology setting? Definition of the Nursing Time Required by Clinical Trial-Assessment Tool (NTRCT-AT).

PubMed

Milani, Alessandra; Mazzocco, Ketti; Stucchi, Sara; Magon, Giorgio; Pravettoni, Gabriella; Passoni, Claudia; Ciccarelli, Chiara; Tonali, Alessandra; Profeta, Teresa; Saiani, Luisa

2017-02-01

Few resources are available to quantify clinical trial-associated workload, needed to guide staffing and budgetary planning. The aim of the study is to describe a tool to measure clinical trials nurses' workload expressed in time spent to complete core activities. Clinical trials nurses drew up a list of nursing core activities, integrating results from literature searches with personal experience. The final 30 core activities were timed for each research nurse by an outside observer during daily practice in May and June 2014. Average times spent by nurses for each activity were calculated. The "Nursing Time Required by Clinical Trial-Assessment Tool" was created as an electronic sheet that combines the average times per specified activities and mathematic functions to return the total estimated time required by a research nurse for each specific trial. The tool was tested retrospectively on 141 clinical trials. The increasing complexity of clinical research requires structured approaches to determine workforce requirements. This study provides a tool to describe the activities of a clinical trials nurse and to estimate the associated time required to deliver individual trials. The application of the proposed tool in clinical research practice could provide a consistent structure for clinical trials nursing workload estimation internationally. © 2016 John Wiley & Sons Australia, Ltd.

What are the primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience?

PubMed

Levett-Jones, Tracy; Pitt, Victoria; Courtney-Pratt, Helen; Harbrow, Gwyneth; Rossiter, Rachel

2015-07-01

Nursing students' first clinical placement experience can be a critical turning point -reinforcing professional aspirations for some, and for others, a time of emotional turbulence. There is a paucity of research focusing on students' perceptions and concerns prior to their first placement experience. Thus, the aim of this study was to explore the concerns of first year bachelor of nursing students from one Australian university as they prepared for their first clinical placement. Participants completed an online 'readiness for practice' survey consisting of 22 items. This paper focuses on participants' responses to the one open ended question: 'Please comment on any concerns that you have in relation to being prepared for your first clinical placement'. Summative qualitative content analysis was used for analysis. 144 students (55%) responded to the open ended question. Responses were categorised into six themes including: Not prepared for placement; feeling nervous, anxious and worried; bullying and belonging; practicalities; patient safety and making mistakes; and working outside of my scope of practice. It appears that activities designed to equip students with the capacity to manage the inherent challenges of undertaking a clinical placement may sometimes have a paradoxical effect by increasing students' level of stress and anxiety. An enhanced understanding of students' concerns may help educators implement appropriate support strategies. Copyright © 2015 Elsevier Ltd. All rights reserved.

Physiotherapy clinical educators' perspectives on a fitness to practice initiative.

PubMed

Lo, Kristin; Curtis, Heather; Francis-Cracknell, Alison; Maloney, Stephen; Nickson, Wendy; Bearman, Margaret; Keating, Jennifer L

2018-01-01

Health practitioner registration boards require health professionals to evaluate and maintain "fitness to practice" (FTP). This encompasses the professional behavior, clinical competence, and freedom from impairment required for safe and effective service provision. We developed and implemented policies to promote student self-assessment and support of FTP that were pre-emptive and designed to be helpful and sought clinician feedback on this initiative. An innovative student-centered FTP approach was devised with consideration of defensible ethico-legal practice. A survey explored clinical educators' perceptions of the FTP policy and the associated education and support. Closed and open survey questions were analyzed using descriptive statistics, qualitative evaluation, and thematic analysis. Seventy-nine physiotherapy clinical educators from 34 sites across eight Australian health services returned surveys. Educators had positive perceptions of policy components, particularly incorporating professionalism as a hurdle requirement and the attendance and incident reporting policies. The benefits of a student-centered FTP approach included clarity and consistency in managing FTP issues and facilitation of student awareness through active engagement in maintaining their FTP. To our knowledge, this paper is the first to report a comprehensive approach to the range of FTP issues incorporating student self-declaration of issues that may affect desirable progression through clinical placements. The policy and program of education and support are likely to be generalizable to health professional training programs that utilize workplace training.

Concordances and discrepancies between ICD-10 and DSM-IV criteria for anxiety disorders in childhood and adolescence

PubMed Central

2012-01-01

Background Mental disorders are classified by two major nosological systems, the ICD-10 and the DSM-IV-TR, consisting of different diagnostic criteria. The present study investigated the diagnostic concordance between the two systems for anxiety disorders in childhood and adolescence, in particular for separation anxiety disorder (SAD), specific phobia, social phobia, and generalized anxiety disorder (GAD). Methods A structured clinical interview, the Kinder-DIPS, was administered to 210 children and 258 parents. The percentage of agreement, kappa, and Yule’s Y coefficients were calculated for all diagnoses. Specific criteria causing discrepancies between the two classification systems were identified. Results DSM-IV-TR consistently classified more children than ICD-10 with an anxiety disorder, with a higher concordance between DSM-IV-TR and the ICD-10 child section (F9) than with the adult section (F4) of the ICD-10. This result was found for all four investigated anxiety disorders. The results revealed low to high levels of concordance and poor to good agreement between the classification systems, depending on the anxiety disorder. Conclusions The two classification systems identify different children with an anxiety disorder. However, it remains an open question, whether the research results can be generalized to clinical practice since DSM-IV-TR is mainly used in research while ICD-10 is widely established in clinical practice in Europe. Therefore, the population investigated by the DSM (research population) is not identical with the population examined using the ICD (clinical population). PMID:23267678

[Accuracy of three methods for the rapid diagnosis of oral candidiasis].

PubMed

Lyu, X; Zhao, C; Yan, Z M; Hua, H

2016-10-09

Objective: To explore a simple, rapid and efficient method for the diagnosis of oral candidiasis in clinical practice. Methods: Totally 124 consecutive patients with suspected oral candidiasis were enrolled from Department of Oral Medicine, Peking University School and Hospital of Stomatology, Beijing, China. Exfoliated cells of oral mucosa and saliva or concentrated oral rinse) obtained from all participants were tested by three rapid smear methods(10% KOH smear, gram-stained smear, Congo red stained smear). The diagnostic efficacy(sensitivity, specificity, Youden's index, likelihood ratio, consistency, predictive value and area under curve(AUC) of each of the above mentioned three methods was assessed by comparing the results with the gold standard(combination of clinical diagnosis, laboratory diagnosis and expert opinion). Results: Gram-stained smear of saliva(or concentrated oral rinse) demonstrated highest sensitivity(82.3%). Test of 10%KOH smear of exfoliated cells showed highest specificity(93.5%). Congo red stained smear of saliva(or concentrated oral rinse) displayed highest diagnostic efficacy(79.0% sensitivity, 80.6% specificity, 0.60 Youden's index, 4.08 positive likelihood ratio, 0.26 negative likelihood ratio, 80% consistency, 80.3% positive predictive value, 79.4% negative predictive value and 0.80 AUC). Conclusions: Test of Congo red stained smear of saliva(or concentrated oral rinse) could be used as a point-of-care tool for the rapid diagnosis of oral candidiasis in clinical practice. Trial registration: Chinese Clinical Trial Registry, ChiCTR-DDD-16008118.

A critical review of recent clinical practice guidelines on the diagnosis and treatment of non-neurogenic male lower urinary tract symptoms

PubMed Central

Chua, Michael Erlano; Mendoza, Jonathan; See, Manuel; Esmena, Ednalyn; Aguila, Dean; Silangcruz, Jan Michael; Reyes, Buenaventura Jose; Luna, Saturnino; Morales, Marcelino

2015-01-01

Introduction: We provide an overview of the quality of recent clinical clinical practice guidelines (CPGs) for non-neurogenic male lower urinary tract symptoms (LUTS) and summarize the recommendations for their diagnosis, assessment, and treatment. Methods: We systematically searched recent (2008–2013) CPGs for non-neurogenic male LUTS. Eligible CPGs were assessed and appraised using Appraisal of Guidelines, Research and Evaluation II (AGREE II) tool by a CPG-appraisal group. The appraisal scores for each guideline were summarized according to each domain and in total. A recommendation summary was made across the guidelines for diagnostics, conservative management, medical, minimally invasive therapy, and surgical management. Results: A total of 8 guidelines were considered. According to AGREE II appraisal of guidelines, the National Institute for Health and Clinical Excellence (NICE), American Urological Association (AUA) and European Association of Urology (EAU) consistently scored high on the guideline domains assessed. Recommendations on diagnostics, conservative management, medical, and surgical management were consistent among the top 3 guidelines. However, we noted a discrepancy in recommending minimally invasive therapy as an alternative management of moderate to severe or bothersome non-neurogenic male LUTS secondary to benign prostatic enlargement (BPE); the NICE guideline, in particular, does not recommend using minimally invasive therapy. Conclusion: The quality of recent CPGs on non-neurogenic male LUTS was appraised and summarized. The guidelines from NICE, AUA and EAU were considered highly compliant to the AGREE II proposition for guideline formation and development. PMID:26279717

A critical review of recent clinical practice guidelines on the diagnosis and treatment of non-neurogenic male lower urinary tract symptoms.

PubMed

Chua, Michael Erlano; Mendoza, Jonathan; See, Manuel; Esmena, Ednalyn; Aguila, Dean; Silangcruz, Jan Michael; Reyes, Buenaventura Jose; Luna, Saturnino; Morales, Marcelino

2015-01-01

We provide an overview of the quality of recent clinical clinical practice guidelines (CPGs) for non-neurogenic male lower urinary tract symptoms (LUTS) and summarize the recommendations for their diagnosis, assessment, and treatment. We systematically searched recent (2008-2013) CPGs for non-neurogenic male LUTS. Eligible CPGs were assessed and appraised using Appraisal of Guidelines, Research and Evaluation II (AGREE II) tool by a CPG-appraisal group. The appraisal scores for each guideline were summarized according to each domain and in total. A recommendation summary was made across the guidelines for diagnostics, conservative management, medical, minimally invasive therapy, and surgical management. A total of 8 guidelines were considered. According to AGREE II appraisal of guidelines, the National Institute for Health and Clinical Excellence (NICE), American Urological Association (AUA) and European Association of Urology (EAU) consistently scored high on the guideline domains assessed. Recommendations on diagnostics, conservative management, medical, and surgical management were consistent among the top 3 guidelines. However, we noted a discrepancy in recommending minimally invasive therapy as an alternative management of moderate to severe or bothersome non-neurogenic male LUTS secondary to benign prostatic enlargement (BPE); the NICE guideline, in particular, does not recommend using minimally invasive therapy. The quality of recent CPGs on non-neurogenic male LUTS was appraised and summarized. The guidelines from NICE, AUA and EAU were considered highly compliant to the AGREE II proposition for guideline formation and development.

Simulation and Shoulder Dystocia.

PubMed

Shaddeau, Angela K; Deering, Shad

2016-12-01

Shoulder dystocia is an unpredictable obstetric emergency that requires prompt interventions to ensure optimal outcomes. Proper technique is important but difficult to train given the urgent and critical clinical situation. Simulation training for shoulder dystocia allows providers at all levels to practice technical and teamwork skills in a no-risk environment. Programs utilizing simulation training for this emergency have consistently demonstrated improved performance both during practice drills and in actual patients with significantly decreased risks of fetal injury. Given the evidence, simulation training for shoulder dystocia should be conducted at all institutions that provide delivery services.

The efficacy of self-directed modules for clinical learning: advanced competencies in entry-level physical therapy education.

PubMed

Peck, Kirk; Paschal, Karen; Black, Lisa; Nelson, Kelly

2014-01-01

Prior to graduation, students often express an interest to advance clinical and professional skills in teaching, research, administration, and various niche practice areas. The acquisition of advanced education in selected areas of practice is believed to improve employment opportunities, accelerate career advancement including eligibility for professional certifications, and contribute to personal satisfaction in the profession. The purpose of this paper is to (1) describe an innovative model of education, the Directed Practice Experience (DPE) elective, that incorporates a student-initiated learning process designed to achieve student-identified professional goals, and (2) report the outcomes for graduates who have completed the DPE in an entry-level program in physical therapy education. Students who met select criteria were eligible to complete a DPE. Applicants designed a 4- to 6-week clinical education experience consisting of stated rationale for personal and professional growth, examples of leadership and service, and self-directed objectives that are beyond entry-level expectations as measured by the revised Physical Therapist Clinical Performance Instrument, version 2006. Twenty-six students have completed DPEs since 2005. Fifty percent resulted in new academic partnerships. At least 25% of graduates now serve as clinical instructors for the entry-level program. Those who participated in DPEs have also completed post-graduate residencies, attained ABPTS Board certifications, authored peer-reviewed publications, and taught in both PT and residency programs. The DPE model allows qualified students to acquire advanced personal skills and knowledge prior to graduation in areas of professional practice that exceed entry-level expectations. The model is applicable to all CAPTE accredited physical therapy education programs and is especially beneficial for academic programs desiring to form new community partnerships for student clinical education.

Enhancing clinical decision making: development of a contiguous definition and conceptual framework.

PubMed

Tiffen, Jennifer; Corbridge, Susan J; Slimmer, Lynda

2014-01-01

Clinical decision making is a term frequently used to describe the fundamental role of the nurse practitioner; however, other terms have been used interchangeably. The purpose of this article is to begin the process of developing a definition and framework of clinical decision making. The developed definition was "Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action." A contiguous framework for clinical decision making specific for nurse practitioners is also proposed. Having a clear and unique understanding of clinical decision making will allow for consistent use of the term, which is relevant given the changing educational requirements for nurse practitioners and broadening scope of practice. Copyright © 2014 Elsevier Inc. All rights reserved.

Connecting clinical and actuarial prediction with rule-based methods.

PubMed

Fokkema, Marjolein; Smits, Niels; Kelderman, Henk; Penninx, Brenda W J H

2015-06-01

Meta-analyses comparing the accuracy of clinical versus actuarial prediction have shown actuarial methods to outperform clinical methods, on average. However, actuarial methods are still not widely used in clinical practice, and there has been a call for the development of actuarial prediction methods for clinical practice. We argue that rule-based methods may be more useful than the linear main effect models usually employed in prediction studies, from a data and decision analytic as well as a practical perspective. In addition, decision rules derived with rule-based methods can be represented as fast and frugal trees, which, unlike main effects models, can be used in a sequential fashion, reducing the number of cues that have to be evaluated before making a prediction. We illustrate the usability of rule-based methods by applying RuleFit, an algorithm for deriving decision rules for classification and regression problems, to a dataset on prediction of the course of depressive and anxiety disorders from Penninx et al. (2011). The RuleFit algorithm provided a model consisting of 2 simple decision rules, requiring evaluation of only 2 to 4 cues. Predictive accuracy of the 2-rule model was very similar to that of a logistic regression model incorporating 20 predictor variables, originally applied to the dataset. In addition, the 2-rule model required, on average, evaluation of only 3 cues. Therefore, the RuleFit algorithm appears to be a promising method for creating decision tools that are less time consuming and easier to apply in psychological practice, and with accuracy comparable to traditional actuarial methods. (c) 2015 APA, all rights reserved).

Pediatric HIV Clinical Care Resources and Management Practices in Asia: A Regional Survey of the TREAT Asia Pediatric Network

PubMed Central

Bowen, Asha C.; Pang, Joselyn; Hesp, Cees; Kariminia, Azar; Sohn, Annette H.

2010-01-01

Abstract Characterizing intraregional differences in current pediatric HIV care and treatment in Asia can guide the development of clinical practice guidelines and improve the understanding of local resource availability. The Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) Pediatric Program is a collaboration of clinics and referral hospitals studying pediatric HIV outcomes in the region. A Web-based survey to characterize clinical management practices and monitoring resources was developed and distributed to 20 sites in January 2008. Seventeen (85%) sites from 6 countries responded through April 2008; 14 (82%) were hospital-based and 16 (94%) were public facilities. Of 4050 HIV-infected children under care, 3606 (89%) were on antiretroviral treatment; 80% were on their first mono-, dual-, or triple-drug regimen and 74% were on nevirapine- or efavirenz-based regimens. Fifteen (88%) sites had consistent access to polymerase chain reaction (PCR) testing for infant diagnosis. All sites had access to CD4 testing, with 13 (76%) routinely monitoring patients every 3–6 months; 7 (41%) sites monitored viral load at 6- to 12-month intervals. Although there is some variation in clinical practices, high levels of treatment and monitoring resources were available at these sites. The availability of PCR for early infant diagnosis positions them to implement recent WHO recommendations to treat HIV-infected children younger than 1 year of age. This information will be used to develop future research and programs to support children with HIV in Asia. PMID:20059355

Systematic evaluation of clinical practice guidelines for pharmacogenomics.

PubMed

Beckett, Robert D; Kisor, David F; Smith, Thomas; Vonada, Brooke

2018-06-01

To systematically assess methodological quality of pharmacogenomics clinical practice guidelines. Guidelines published through 2017 were reviewed by at least three independent reviewers using the AGREE II instrument, which consists of 23 items grouped into 6 domains and 2 items representing an overall assessment. Items were assessed on a seven-point rating scale, and aggregate quality scores were calculated. 31 articles were included. All guidelines were published as peer-reviewed articles and 90% (n = 28) were endorsed by professional organizations. Mean AGREE II domain scores (maximum score 100%) ranged from 46.6 ± 11.5% ('applicability') to 78.9 ± 11.4% ('clarity of presentation'). Median overall quality score was 72.2% (IQR: 61.1-77.8%). Quality of pharmacogenomics guidelines was generally high, but variable, for most AGREE II domains.

Determination of nursing diagnoses used by students in the first clinical practice.

PubMed

Türk, Gülengün; Tuğrul, Emel; Sahbaz, Muazzez

2013-10-01

This study was carried out descriptively with the purpose of determining nursing diagnoses that nursing freshmen students used in their first clinical practice. The sample of the study consisted of 61 nursing students. Data of the study were collected with the examination of 208 care plans that the students had prepared. Nursing diagnoses in the examined care plans were classified according to nursing diagnoses grouped under the domains of Taxonomy II NANDA-I. Students determined 31 different diagnoses in nine domains of NANDA-I. Total nursing diagnoses used in care plans were 635. It was determined that the nursing diagnoses that the students mostly used, according to classification of NANDA-I, were in the domains of safety/protection, activity/rest, comfort, elimination and exchange, and nutrition. © 2013 NANDA International.

Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs.

PubMed

Mwangi, Nyawira; Gachago, Muchai; Gichangi, Michael; Gichuhi, Stephen; Githeko, Kibata; Jalango, Atieno; Karimurio, Jefitha; Kibachio, Joseph; Muthami, Lawrence; Ngugi, Nancy; Nduri, Carmichael; Nyaga, Patrick; Nyamori, Joseph; Zindamoyen, Alain Nazaire Mbongo; Bascaran, Covadonga; Foster, Allen

2018-06-15

The use of clinical practice guidelines envisages augmenting quality and best practice in clinical outcomes. Generic guidelines that are not adapted for local use often fail to produce these outcomes. Adaptation is a systematic and rigorous process that should maintain the quality and validity of the guideline, while making it more usable by the targeted users. Diverse skills are required for the task of adaptation. Although adapting a guideline is not a guarantee that it will be implemented, adaptation may improve acceptance and adherence to its recommendations. We describe the process used to adapt clinical guidelines for diabetic retinopathy in Kenya, using validated tools and manuals. A technical working group consisting of volunteers provided leadership. The process was intensive and required more time than anticipated. Flexibility in the process and concurrent health system activities contributed to the success of the adaptation. The outputs from the adaptation include the guidelines in different formats, point of care instruments, as well as tools for training, monitoring, quality assurance and patient education. Guideline adaptation is applicable and feasible at the national level in Kenya. However, it is labor- and time -intensive. It presents a valuable opportunity to develop several additional outputs that are useful at the point of care.

Relevance and attitudes toward histology and embryology course through the eyes of freshmen and senior medical students: Experience from Serbia.

PubMed

Zaletel, Ivan; Marić, Gorica; Gazibara, Tatjana; Rakočević, Jelena; Labudović Borović, Milica; Puškaš, Nela; Bajčetić, Miloš

2016-11-01

Histology and embryology are prerequisite for understanding the complexity of cell and tissue organization, function and development. The aim of this study was to examine the attitudes of medical students toward relevance of histology and embryology in their pre-clinical and clinical medical practice. The study sample consisted of 900 undergraduate students of 1st and 6th study year at the School of Medicine in Belgrade, Serbia. Data were collected using an anonymous questionnaire. Senior students reported the relevance of histology and embryology knowledge for learning pathology, dermatology, physiology, gynecology and obstetrics, pathophysiology and pediatrics. Examination of students' attitudes revealed that 1st year participants more often acknowledged histology and embryology as being of great importance for their professional career. Analysis according to gender indicated that female students consider embryology as of greater importance for further medical education and future clinical practice than male students. Overall, study results suggest that medical students have a positive attitude toward histology and embryology undergraduate course. This evidence could be used as an additional motive for the development of histology and embryology courses, with special emphasis on practical application of knowledge in clinically-oriented setting. Copyright © 2016 Elsevier GmbH. All rights reserved.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline*

PubMed Central

Wilson, Christine; Dentice, Ruth; Cox, Narelle S.; Middleton, Anna; Tannenbaum, Esta; Bishop, Jennifer; Cobb, Robyn; Burton, Kate; Wood, Michelle; Moran, Fiona; Black, Ryan; Bowen, Summar; Day, Rosemary; Depiazzi, Julie; Doiron, Katherine; Doumit, Michael; Dwyer, Tiffany; Elliot, Alison; Fuller, Louise; Hall, Kathleen; Hutchins, Matthew; Kerr, Melinda; Lee, Annemarie L.; Mans, Christina; O'Connor, Lauren; Steward, Ranjana; Potter, Angela; Rasekaba, Tshepo; Scoones, Rebecca; Tarrant, Ben; Ward, Nathan; West, Samantha; White, Dianne; Wilson, Lisa; Wood, Jamie; Holland, Anne E.

2016-01-01

Abstract Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non‐invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence‐based physiotherapy care to people with CF in Australia and New Zealand. PMID:27086904

A survey validation and analysis of undergraduate medical biochemistry practical curriculum in maharashtra, India.

PubMed

Dandekar, Sucheta P; Maksane, Shalini N; McKinley, Danette

2012-01-01

In order to review the strengths and weaknesses of medical biochemistry practical curriculum for undergraduates and to generate ideas to improve it, a questionnaire was sent to 50 biochemistry faculty members selected (through simple random sampling method) from 42 medical colleges of Maharashtra, India. 39 responded to the questionnaire, representing a 78% response rate. The internal consistency of the questionnaire sections was found to be satisfactory (>0.7). The respondents did not agree that the ongoing curriculum was in alignment with learning outcomes (8%), that it encouraged active learning (28%), helped to apply knowledge to clinical situations (18%) and promoted critical thinking and problem solving skills (28%). There were a number of qualitative experiments that were rated 'irrelevant'. Qualitative and quantitative experiments related to recent advances were suggested to be introduced by the respondents. Checklists for the practicals and new curriculum objectives provided in the questionnaire were also approved. The results of the curriculum evaluation suggest a need for re-structuring of practical biochemistry curriculum and introduction of a modified curriculum with more clinical relevance.

Role of Leadership in Narrowing the Gap between Science and Practice: Improving Treatment Outcomes at the Systems Level.

PubMed

Saeed, Sy Atezaz; Bloch, Richard M; Silver, Stuart

2015-09-01

It's been well documented that health care does not reliably transfer what we know from science into clinical practice. As a result, Americans do not always receive the care suggested by the scientific evidence. Despite the best intentions of a dedicated and skilled healthcare workforce, this can often lead to poor clinical outcomes. As research and technology rapidly advance, this gap between science and practice appears to be widening. There is an increasing public concern about a lack of access to appropriate treatment, pervasiveness of unsafe practices, and wasteful uses of precious health care resources leading to suboptimum treatment outcomes. Leadership has a critical role in creating and sustaining the environment that supports health services for individuals and populations that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Leadership has some responsibility to improve outcomes by insuring effective use of evidence-based treatment guidelines; measurement-based care; knowledge and skills management; care coordination; and information technologies. This paper addresses leadership issues in these components of a system's ability to improve treatment outcomes.

Creating Discursive Order at the End of Life: The Role of Genres in Palliative Care Settings

ERIC Educational Resources Information Center

Schryer, Catherine; McDougall, Allan; Tait, Glendon R.; Lingard, Lorelei

2012-01-01

This article investigates an emerging practice in palliative care: dignity therapy. Dignity therapy is a psychotherapeutic intervention that its proponents assert has clinically significant positive impacts on dying patients. Dignity therapy consists of a physician asking a patient a set of questions about his or her life and returning to the…

A Practice Concepts Symposium on Drug Misuse in the Elderly: Examination of a Case History.

ERIC Educational Resources Information Center

Silverstone, Barbara; And Others

1986-01-01

Set of articles consisting of an introduction (Barbara Silverstone, et al.) and case study concerning drug misuse in the elderly, and six papers examining the case from the perspectives of clinical pharmacology (William Simonson); pharmacology (Peter Lamy); psychiatry (Charles Gaitz and Nancy Wilson); nursing (Delores Alford); social work (Janet…

Perspectives on Technology-Assisted Relaxation Approaches to Support Mind-Body Skills Practice in Children and Teens: Clinical Experience and Commentary

PubMed Central

Culbert, Timothy

2017-01-01

It has been well-established that a variety of mind-body (MB) techniques, including yoga, mental imagery, hypnosis, biofeedback, and meditation, are effective at addressing symptoms such as pain, anxiety, nausea, and insomnia, as well as helping with a wide variety of medical, emotional, and behavioral issues in pediatric populations. In addition, MB skills can also be health-promoting in the long-term, and with regular practice, could potentially contribute to longer attention spans, social skills, emotional regulation, and enhanced immune system functioning. Importantly, the benefits accrued from MB skills are largely dose-dependent, meaning that individuals who practice with some consistency tend to benefit the most, both in the short- and long-term. However, clinical experience suggests that for busy patients, the regular practice of MB skills can be challenging and treatment adherence commonly becomes an issue. This commentary reviews the concept of technology-assisted relaxation as an engaging and effective option to enhance treatment adherence (i.e., daily practice) for pediatric patients, for whom MB skills have been recommended to address physical and mental health challenges. PMID:28375179

Controlled trials to improve antibiotic utilization: a systematic review of experience, 1984-2004.

PubMed

Parrino, Thomas A

2005-02-01

To review the effectiveness of interventions designed to improve antibiotic prescribing patterns in clinical practice and to draw inferences about the most practical methods for optimizing antibiotic utilization in hospital and ambulatory settings. A literature search using online databases for the years 1975-2004 identified controlled trials of strategies for improving antibiotic utilization. Due to variation in study settings and design, quantitative meta-analysis was not feasible. Therefore, a qualitative literature review was conducted. Forty-one controlled trials met the search criteria. Interventions consisted of education, peer review and feedback, physician participation, rewards and penalties, administrative methods, and combined approaches. Social marketing directed at patients and prescribers was effective in varying contexts, as was implementation of practice guidelines. Authorization systems with structured order entry, formulary restriction, and mandatory consultation were also effective. Peer review and feedback were more effective when combined with dissemination of relevant information or social marketing than when used alone. Several practices were effective in improving antibiotic utilization: social marketing, practice guidelines, authorization systems, and peer review and feedback. Online systems providing clinical information, structured order entry, and decision support may be the most promising approach. Further studies, including economic analyses, are needed to confirm or refute this hypothesis.

Understanding physical activity promotion in physiotherapy practice: A qualitative study.

PubMed

Lowe, Anna; Littlewood, Chris; McLean, Sionnadh

2018-06-01

Physical inactivity is a major public health issue and healthcare professionals are encouraged to promote physical activity during routine patient contacts in order to reduce non-communicable diseases and enhance individuals' quality of life. Little is known about physical activity promotion in physiotherapy practice in the UK. The aim of this study was to better understand physiotherapists' experience of physical activity promotion in clinical practice. A qualitative study was undertaken comprising 12 telephone interviews with participants using a quota sampling approach. The qualitative data was analysed using a thematic analysis approach and written up according to COREQ guidelines. Four themes were identified (1) Current physiotherapy practice (2) Barriers to, and facilitators of physical activity promotion, (3) Exercise or physical activity? and (4) Functional restoration versus general wellbeing. Physiotherapists use routine clinical contacts to discuss physical activity. However, brief interventions are not consistently used and no common framework to guide physical activity promotion was identified. Approaches appear to be inconsistent and informal and focus largely on short-term restoration of function rather than health promotion. There is scope to improve practice in line with current guidance to maximise potential impact on inactivity. Copyright © 2018 Elsevier Ltd. All rights reserved.

Application of best practice guidelines for OSCEs-An Australian evaluation of their feasibility and value.

PubMed

Mitchell, Marion L; Henderson, Amanda; Jeffrey, Carol; Nulty, Duncan; Groves, Michele; Kelly, Michelle; Knight, Sabina; Glover, Pauline

2015-05-01

Objective Structured Clinical Examinations (OSCEs) are widely used in health professional education and should be based on sound pedagogical foundations. The aim of this study is to evaluate the feasibility and utility of using Best Practice Guidelines (BPGs) within an OSCE format in a broad range of tertiary education settings with under-graduate and post-graduate nursing and midwifery students. We evaluated how feasible it was to apply the BPGs to modify OSCEs in a course; students' perspective of the OSCE; and finally, if the BPG-revised OSCEs better prepared students for clinical practice when compared with the original OSCEs. A mixed method with surveys, focus groups and semi-structured interviews evaluated the BPGs within an OSCE. Four maximally different contexts across four sites in Australia were used. Participants included lecturers and undergraduate nursing students in high and low fidelity simulation settings; under-graduate midwifery students; and post-graduate rural and remote area nursing students. 691 students participated in revised OSCEs. Surveys were completed by 557 students; 91 students gave further feedback through focus groups and 14 lecturers participated in interviews. At all sites the BPGs were successfully used to modify and implement OSCEs. Students valued the realistic nature of the modified OSCEs which contributed to students' confidence and preparation for clinical practice. The lecturers considered the revised OSCEs enhanced student preparedness for their clinical placements. The BPGs have a broad applicability to OSCEs in a wide range of educational contexts with improved student outcomes. Students and lecturers identified the revised OSCEs enhanced student preparation for clinical practice. Subsequent examination of the BPGs saw further refinement to a set of eight BPGs that provide a sequential guide to their application in a way that is consistent with best practice curriculum design principles. Copyright © 2015 Elsevier Ltd. All rights reserved.

Exploratory factor analysis of the Clinical Learning Environment, Supervision and Nurse Teacher Scale (CLES+T).

PubMed

Watson, Paul Barry; Seaton, Philippa; Sims, Deborah; Jamieson, Isabel; Mountier, Jane; Whittle, Rose; Saarikoski, Mikko

2014-01-01

The Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T) scale measures student nurses' perceptions of clinical learning environments. This study evaluates the construct validity and internal reliability of the CLES+T in hospital settings in New Zealand. Comparisons are made between New Zealand and Finnish data. The CLES+T scale was completed by 416 Bachelor of Nursing students following hospital clinical placements between October 2008 and December 2009. Construct validity and internal reliability were assessed using exploratory factor analysis and Cronbach's alpha. Exploratory factor analysis supports 4 factors. Cronbach's alpha ranged from .82 to .93. All items except 1 loaded on the same factors found in unpublished Finnish data. The first factor combined 2 previous components from the published Finnish component analysis and was renamed: connecting with, and learning in, communities of clinical practice. The remaining 3 factors (Nurse teacher, Supervisory relationship, and Leadership style of the manager) corresponded to previous components and their conceptualizations. The CLES+T has good internal reliability and a consistent factor structure across samples. The consistency across international samples supports faculties and hospitals using the CLES+T to benchmark the quality of clinical learning environments provided to students.

Clinical Reasoning: Survey of Teaching Methods, Integration, and Assessment in Entry-Level Physical Therapist Academic Education.

PubMed

Christensen, Nicole; Black, Lisa; Furze, Jennifer; Huhn, Karen; Vendrely, Ann; Wainwright, Susan

2017-02-01

Although clinical reasoning abilities are important learning outcomes of physical therapist entry-level education, best practice standards have not been established to guide clinical reasoning curricular design and learning assessment. This research explored how clinical reasoning is currently defined, taught, and assessed in physical therapist entry-level education programs. A descriptive, cross-sectional survey was administered to physical therapist program representatives. An electronic 24-question survey was distributed to the directors of 207 programs accredited by the Commission on Accreditation in Physical Therapy Education. Descriptive statistical analysis and qualitative content analysis were performed. Post hoc demographic and wave analyses revealed no evidence of nonresponse bias. A response rate of 46.4% (n=96) was achieved. All respondents reported that their programs incorporated clinical reasoning into their curricula. Only 25% of respondents reported a common definition of clinical reasoning in their programs. Most respondents (90.6%) reported that clinical reasoning was explicit in their curricula, and 94.8% indicated that multiple methods of curricular integration were used. Instructor-designed materials were most commonly used to teach clinical reasoning (83.3%). Assessment of clinical reasoning included practical examinations (99%), clinical coursework (94.8%), written examinations (87.5%), and written assignments (83.3%). Curricular integration of clinical reasoning-related self-reflection skills was reported by 91%. A large number of incomplete surveys affected the response rate, and the program directors to whom the survey was sent may not have consulted the faculty members who were most knowledgeable about clinical reasoning in their curricula. The survey construction limited some responses and application of the results. Although clinical reasoning was explicitly integrated into program curricula, it was not consistently defined, taught, or assessed within or between the programs surveyed-resulting in significant variability in clinical reasoning education. These findings support the need for the development of best educational practices for clinical reasoning curricula and learning assessment. © 2017 American Physical Therapy Association

Confronting the caring crisis in clinical practice.

PubMed

Ma, Fang; Li, Jiping; Zhu, Dan; Bai, Yangjuan; Song, Jianhua

2013-10-01

In light of the call for humanistic caring in the contemporary health care system globally and in China, the issue of improving the caring skills that are essential to student success, high-quality nursing practice and positive patient outcomes is at the forefront of nursing education. The aim of this mixed-methods quantitative and qualitative study was to investigate baccalaureate nursing students' caring ability in the context of China and to explore the role of clinical practice learning in the development of students' caring skills. A two-phase, descriptive study utilising a mixed methodology consisting of a caring ability survey and focus group interviews was conducted. In the quantitative phase, 598 baccalaureate nursing students at two colleges in Yunnan Province in southwest China were surveyed using the Caring Ability Inventory (CAI). In the qualitative phase, 16 of the students who had participated in the quantitative phase were interviewed. Students obtained lower scores on the CAI than have been reported elsewhere by other researchers. In addition, students in the clinical stage of training scored lower than students in the pre-clinical stage. Three themes concerning facilitation by and three themes concerning the obstructive effects of clinical practice learning in the development of caring ability were identified. Themes pertaining to facilitation were: (i) promoting a sense of professional responsibility and ethics; (ii) providing an arena in which to practise caring, and (iii) learning from positive role models. Themes pertaining to obstruction were: (i) a critical practice learning environment; (ii) encountering inappropriate clinical teachers, and (iii) experiencing shock at the contrast between an idealised and the real environment. The key to developing students' ability to care lies in highlighting caring across the entire health care system. By diminishing exposure to negative role models, and adopting appropriate pedagogical ideas about education in caring, such as truth telling and helping students to think in a critical manner, educators can help students to improve their caring ability. © 2013 John Wiley & Sons Ltd.

SPIRIT: Systematic Planning of Intelligent Reuse of Integrated Clinical Routine Data. A Conceptual Best-practice Framework and Procedure Model.

PubMed

Hackl, W O; Ammenwerth, E

2016-01-01

Secondary use of clinical routine data is receiving an increasing amount of attention in biomedicine and healthcare. However, building and analysing integrated clinical routine data repositories are nontrivial, challenging tasks. As in most evolving fields, recognized standards, well-proven methodological frameworks, or accurately described best-practice approaches for the systematic planning of solutions for secondary use of routine medical record data are missing. We propose a conceptual best-practice framework and procedure model for the systematic planning of intelligent reuse of integrated clinical routine data (SPIRIT). SPIRIT was developed based on a broad literature overview and further refined in two case studies with different kinds of clinical routine data, including process-oriented nursing data from a large hospital group and high-volume multimodal clinical data from a neurologic intensive care unit. SPIRIT aims at tailoring secondary use solutions to specific needs of single departments without losing sight of the institution as a whole. It provides a general conceptual best-practice framework consisting of three parts: First, a secondary use strategy for the whole organization is determined. Second, comprehensive analyses are conducted from two different viewpoints to define the requirements regarding a clinical routine data reuse solution at the system level from the data perspective (BOTTOM UP) and at the strategic level from the future users perspective (TOP DOWN). An obligatory clinical context analysis (IN BETWEEN) facilitates refinement, combination, and integration of the different requirements. The third part of SPIRIT is dedicated to implementation, which comprises design and realization of clinical data integration and management as well as data analysis solutions. The SPIRIT framework is intended to be used to systematically plan the intelligent reuse of clinical routine data for multiple purposes, which often was not intended when the primary clinical documentation systems were implemented. SPIRIT helps to overcome this gap. It can be applied in healthcare institutions of any size or specialization and allows a stepwise setup and evolution of holistic clinical routine data reuse solutions.

Lessons learned from a pharmacy practice model change at an academic medical center.

PubMed

Knoer, Scott J; Pastor, John D; Phelps, Pamela K

2010-11-01

The development and implementation of a new pharmacy practice model at an academic medical center are described. Before the model change, decentralized pharmacists responsible for order entry and verification and clinical specialists were both present on the care units. Staff pharmacists were responsible for medication distribution and sterile product preparation. The decentralized pharmacists handling orders were not able to use their clinical training, the practice model was inefficient, and few clinical services were available during evenings and weekends. A task force representing all pharmacy department roles developed a process and guiding principles for the model change, collected data, and decided on a model. Teams consisting of decentralized pharmacists, decentralized pharmacy technicians, and team leaders now work together to meet patients' pharmacy needs and further departmental safety, quality, and cost-saving goals. Decentralized service hours have been expanded through operational efficiencies, including use of automation (e.g., computerized provider order entry, wireless computers on wheels used during rounds with physician teams). Nine clinical specialist positions were replaced by five team leader positions and four pharmacists functioning in decentralized roles. Additional staff pharmacist positions were shifted into decentralized roles, and the hospital was divided into areas served by teams including five to eight pharmacists. Technicians are directly responsible for medication distribution. No individual's job was eliminated. The new practice model allowed better alignment of staff with departmental goals, expanded pharmacy hours and services, more efficient medication distribution, improved employee engagement, and a staff succession plan.

Inter-rater reliability of twelve diagnostic systems of schizophrenia.

PubMed

Helmes, E; Landmark, J; Kazarian, S S

1983-05-01

The present and past symptomatology of 31 chronic schizophrenics was rated by four independent judges, two experienced clinical psychiatrists and two psychiatric residents, in a context more representative of actual clinical practice than most research studies. Ratings were made on 64 symptoms derived from 12 diagnostic systems, based on either live or videotaped interviews for present symptomatology and case records for past symptomatology. Inter-rater reliabilities were higher for present than for past symptoms, and in general did not approach those reported for highly trained raters. There were no differences between live and videotaped interviews. Diagnostic systems differed widely in rater agreement. The most consistent across both past and present symptomatology were the systems of Langfeldt, Schneider, and DSM-III, for which the level of reliability was consistent with other studies.

Tuberculosis management practices of private practitioners in Pune municipal corporation, India.

PubMed

Bharaswadkar, Sandeep; Kanchar, Avinash; Thakur, Narendra; Shah, Shubhangi; Patnaik, Brinda; Click, Eleanor S; Kumar, Ajay M V; Dewan, Puneet Kumar

2014-01-01

Private Practitioners (PP) are the primary source of health care for patients in India. Limited representative information is available on TB management practices of Indian PP or on the efficacy of India's Revised National Tuberculosis Control Programme (RNTCP) to improve the quality of TB management through training of PP. We conducted a cross-sectional survey of a systematic random sample of PP in one urban area in Western India (Pune, Maharashtra). We presented sample clinical vignettes and determined the proportions of PPs who reported practices consistent with International Standards of TB Care (ISTC). We examined the association between RNTCP training and adherence to ISTC by calculating odds ratios and 95% confidence intervals. Of 3,391 PP practicing allopathic medicine, 249 were interviewed. Of these, 55% had been exposed to RNTCP. For new pulmonary TB patients, 63% (158/249) of provider responses were consistent with ISTC diagnostic practices, and 34% (84/249) of responses were consistent with ISTC treatment practices. However, 48% (120/249) PP also reported use of serological tests for TB diagnosis. In the new TB case vignette, 38% (94/249) PP reported use of at least one second line anti-TB drug in the treatment regimen. RNTCP training was not associated with diagnostic or treatment practices. In Pune, India, despite a decade of training activities by the RNTCP, high proportions of providers resorted to TB serology for diagnosis and second-line anti-TB drug use in new TB patients. Efforts to achieve universal access to quality TB management must account for the low quality of care by PP and the lack of demonstrated effect of current training efforts.

Tuberculosis Management Practices of Private Practitioners in Pune Municipal Corporation, India

PubMed Central

Bharaswadkar, Sandeep; Kanchar, Avinash; Thakur, Narendra; Shah, Shubhangi; Patnaik, Brinda; Click, Eleanor S.; Kumar, Ajay M. V.; Dewan, Puneet Kumar

2014-01-01

Background Private Practitioners (PP) are the primary source of health care for patients in India. Limited representative information is available on TB management practices of Indian PP or on the efficacy of India’s Revised National Tuberculosis Control Programme (RNTCP) to improve the quality of TB management through training of PP. Methods We conducted a cross-sectional survey of a systematic random sample of PP in one urban area in Western India (Pune, Maharashtra). We presented sample clinical vignettes and determined the proportions of PPs who reported practices consistent with International Standards of TB Care (ISTC). We examined the association between RNTCP training and adherence to ISTC by calculating odds ratios and 95% confidence intervals. Results Of 3,391 PP practicing allopathic medicine, 249 were interviewed. Of these, 55% had been exposed to RNTCP. For new pulmonary TB patients, 63% (158/249) of provider responses were consistent with ISTC diagnostic practices, and 34% (84/249) of responses were consistent with ISTC treatment practices. However, 48% (120/249) PP also reported use of serological tests for TB diagnosis. In the new TB case vignette, 38% (94/249) PP reported use of at least one second line anti-TB drug in the treatment regimen. RNTCP training was not associated with diagnostic or treatment practices. Conclusion In Pune, India, despite a decade of training activities by the RNTCP, high proportions of providers resorted to TB serology for diagnosis and second-line anti-TB drug use in new TB patients. Efforts to achieve universal access to quality TB management must account for the low quality of care by PP and the lack of demonstrated effect of current training efforts. PMID:24897374

Opinions and practices of healthcare professionals on assessment of disease associated malnutrition in children: Results from an international survey.

PubMed

Huysentruyt, Koen; Hulst, Jessie; Bian, Feifei; Shamir, Raanan; White, Melinda; Galera-Martinez, Raphael; Morais-Lopez, Anna; Kansu, Aydan; Gerasimidis, Konstantinos

2018-04-05

Lack of consensus on clinical indicators for the assessment of pediatric disease associated malnutrition (DAM) may explain its under-recognition in clinical practice. This study surveyed the opinions of health professionals (HP) on clinical indicators of DAM and barriers impeding routine nutritional screening in children. Web-based questionnaire survey (April 2013-August 2015) in Australia, Belgium, Israel, Spain, The Netherlands, Turkey and UK. There were 937 questionnaires returned via local professional associations, of which 693 respondents fulfilled the inclusion criteria and were included in the final analysis; 315 pediatric gastroenterologists and 378 pediatric dieticians. The most important clinical indicators of DAM were ongoing weight loss (80.4%), increased energy/nutrient losses (73.0%), suboptimal energy/macronutrient intake (68.6%), a high nutritional risk condition (67.2%) and increased energy/nutrient requirements (66.2%). These findings were consistent across countries and professions. The most common approach to screen for DAM was assessment of weight changes (85%), followed by the usage of growth charts (77-80%). Common perceived barriers for routine nutritional screening/assessment were low staff awareness (47.5%), no local policy or guidelines (33.4%) and lack of time to screen (33.4%). HP who routinely assess and treat children with DAM identified ongoing weight loss, increased losses, increased requirements, low intake and high nutritional risk conditions as the most important clinical indicators of DAM. These clinical indicators should now serve as a basis to form clinical-based criteria for the identification of DAM in routine clinical practice. Low awareness, lack of guidelines or local policy and lack of resources were the most important barriers of routine screening. Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

A Thematic Inquiry into the Burnout Experience of Australian Solo-Practicing Clinical Psychologists

PubMed Central

Hammond, Trent E.; Crowther, Andrew; Drummond, Sally

2018-01-01

Objective: Burnout is conceptualized as a syndrome that consists of emotional exhaustion, depersonalization, and decreased personal accomplishment. Despite the increased frequency and severity of burnout in the Western world, there is limited published research regarding the experiences of clinical psychologists who have had burnout. The present study examines clinical psychologists’ different experiences of burnout in Australia. Design and Methods: In the year 2015, six privately practicing and solo-employed clinical psychologists provided rich qualitative data by participating in semi-structured interviews. Thematic analysis was the method used to analyze clinical psychologists’ natural accounts of their burnout experiences. Using NVivo, emerging themes were identified through coding ‘first order constructs’ and then axial code ‘second order constructs.’ Findings: Clinical psychologists indicated that their roles are demanding and a diverse range of symptoms, including the enduring effects of burnout, mental stress, fatigue, decreased personal accomplishment, negative affect, depersonalization, reduced productivity and motivation, and insomnia. They identified precursors of burnout, including excessive workload and hours of work, life stresses, mismanaged workload, and transference. Clinical psychologists suggested that protective factors of burnout include knowledge and years worked in direct care, and trusting and long-term relationships. They indicated that the barriers to overcoming burnout include the fallacy that their clients’ expectations and needs are more important than their own, the financial cost of working in private practice, contemporary knowledge and inadequate education regarding self-care, and time constraints. Discussion and Conclusion: The findings presented in this study provide psychologists and other health professionals with an insight about the burnout experience and inform professionals of the mental shortcomings of working as a solo-practicing clinical psychologist. Findings from this study should lead to an increased understanding of the complexities of burnout, and ultimately reduced cases of burnout, absenteeism, and staff disengagement. PMID:29403402

Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management.

PubMed

Gottrup, F; Apelqvist, J; Price, P

2010-06-01

While there is a consensus that clinical practice should be evidence based, this can be difficult to achieve due to confusion about the value of the various approaches to wound management. To address this, the European Wound Management Association (EWMA) set up a Patient Outcome Group whose remit was to produce recommendations on clinical data collection in wound care. This document, produced by the group and disseminated by JWC, identifies criteria for producing rigorous outcomes in both randomised controlled trials and clinical studies, and describes how to ensure studies are consistent and reproducible.

The effectiveness and feasibility of TREAT (Tailoring Research Evidence and Theory) journal clubs in allied health: a randomised controlled trial.

PubMed

Wenke, Rachel J; Thomas, Rae; Hughes, Ian; Mickan, Sharon

2018-05-09

Journal clubs (JC) may increase clinicians' evidence-based practice (EBP) skills and facilitate evidence uptake in clinical practice, however there is a lack of research into their effectiveness in allied health. We investigated the effectiveness of a structured JC that is Tailored According to Research Evidence And Theory (TREAT) in improving EBP skills and practice compared to a standard JC format for allied health professionals. Concurrently, we explored the feasibility of implementing TREAT JCs in a healthcare setting, by evaluating participating clinicians' perceptions and satisfaction. We conducted an explanatory mixed methods study involving a cluster randomised controlled trial with a nested focus group for the intervention participants. Nine JCs with 126 allied health participants were randomly allocated to receive either the TREAT or standard JC format for 1 h/month for 6 months. We conducted pre-post measures of EBP skills and attitudes using the EBP questionnaire and Assessing Competence in Evidence-Based Medicine tool and a tailored satisfaction and practice change questionnaire. Post-intervention, we also conducted a focus group with TREAT participants to explore their perceptions of the format. There were no significant differences between JC formats in EBP skills, knowledge or attitudes or influence on clinical practice, with participants maintaining intermediate level skills across time points. Participants reported significantly greater satisfaction with the organisation of the TREAT format. Participants in both groups reported positive changes to clinical practice. Perceived outcomes to the TREAT format and facilitating mechanisms were identified including the use of an academic facilitator, group appraisal approach and consistent appraisal tools which assisted skill development and engagement. It is feasible to implement an evidence-based JC for allied health clinicians. While clinicians were more satisfied with the TREAT format, it did not significantly improve their EBP skills, attitudes, knowledge and/or practice, when compared to the standard format. The use of an academic facilitator, group based critical appraisal, and the consistent use of appraisal tools were perceived as useful components of the JC format. A structured JC may maintain EBP skills in allied health clinicians and facilitate engagement, however additional training may be required to further enhance EBP skills. ACTRN12616000811404 Retrospectively registered 21 June 2016.

A survey of physics and dosimetry practice of permanent prostate brachytherapy in the United States.

PubMed

Prete, J J; Prestidge, B R; Bice, W S; Friedland, J L; Stock, R G; Grimm, P D

1998-03-01

To obtain data with regard to current physics and dosimetry practice in transperineal interstitial permanent prostate brachytherapy (TIPPB) in the U.S. by conducting a survey of institutions performing this procedure with the greatest frequency. Seventy brachytherapists with the greatest volume of TIPPB cases in 1995 in the U.S. were surveyed. The four-page comprehensive questionnaire included questions on both clinical and physics and dosimetry practice. Individuals not responding initially were sent additional mailings and telephoned. Physics and dosimetry practice summary statistics are reported. Clinical practice data is reported separately. Thirty-five (50%) surveys were returned. Participants included 29 (83%) from the private sector and 6 (17%) from academic programs. Among responding clinicians, 125I (89%) is used with greater frequency than 103Pd (83%). Many use both (71%). Most brachytherapists perform preplans (86%), predominately employing ultrasound imaging (85%). Commercial treatment planning systems are used more frequently (75%) than in-house systems (25%). Preplans take 2.5 h (avg.) to perform and are most commonly performed by a physicist (69%). A wide range of apparent activities (mCi) is used for both 125I (0.16-1.00, avg. 0.41) and 103Pd (0.50-1.90, avg. 1.32). Of those assaying sources (71%), the range in number assayed (1 to all) and maximum accepted difference from vendor stated activity (2-20%) varies greatly. Most respondents feel that the manufacturers criteria for source activity are sufficiently stringent (88%); however, some report that vendors do not always meet their criteria (44%). Most postimplant dosimetry imaging occurs on day 1 (41%) and consists of conventional x-rays (83%), CT (63%), or both (46%). Postimplant dosimetry is usually performed by a physicist (72%), taking 2 h (avg.) to complete. Calculational formalisms and parameters vary substantially. At the time of the survey, few institutions have adopted AAPM TG-43 recommendations (21%). Only half (50%) of those not using TG-43 indicated an intent to do so in the future. Calculated doses at 1 cm from a single 1 mCi apparent activity source permanently implanted varied significantly. For 125I, doses calculated ranged from 13.08-40.00 Gy and for 103Pd, from 3.10 to 8.70 Gy. While several areas of current physics and dosimetry practice are consistent among institutions, treatment planning and dose calculation techniques vary considerably. These data demonstrate a relative lack of consensus with regard to these practices. Furthermore, the wide variety of calculational techniques and benchmark data lead to calculated doses which vary by clinically significant amounts. It is apparent that the lack of standardization with regard to treatment planning and dose calculation practice in TIPPB must be addressed prior to performing any meaningful comparison of clinical results between institutions.

Comparison of locus-specific databases for BRCA1 and BRCA2 variants reveals disparity in variant classification within and among databases.

PubMed

Vail, Paris J; Morris, Brian; van Kan, Aric; Burdett, Brianna C; Moyes, Kelsey; Theisen, Aaron; Kerr, Iain D; Wenstrup, Richard J; Eggington, Julie M

2015-10-01

Genetic variants of uncertain clinical significance (VUSs) are a common outcome of clinical genetic testing. Locus-specific variant databases (LSDBs) have been established for numerous disease-associated genes as a research tool for the interpretation of genetic sequence variants to facilitate variant interpretation via aggregated data. If LSDBs are to be used for clinical practice, consistent and transparent criteria regarding the deposition and interpretation of variants are vital, as variant classifications are often used to make important and irreversible clinical decisions. In this study, we performed a retrospective analysis of 2017 consecutive BRCA1 and BRCA2 genetic variants identified from 24,650 consecutive patient samples referred to our laboratory to establish an unbiased dataset representative of the types of variants seen in the US patient population, submitted by clinicians and researchers for BRCA1 and BRCA2 testing. We compared the clinical classifications of these variants among five publicly accessible BRCA1 and BRCA2 variant databases: BIC, ClinVar, HGMD (paid version), LOVD, and the UMD databases. Our results show substantial disparity of variant classifications among publicly accessible databases. Furthermore, it appears that discrepant classifications are not the result of a single outlier but widespread disagreement among databases. This study also shows that databases sometimes favor a clinical classification when current best practice guidelines (ACMG/AMP/CAP) would suggest an uncertain classification. Although LSDBs have been well established for research applications, our results suggest several challenges preclude their wider use in clinical practice.

Development and Integration of Professional Core Values Among Practicing Clinicians.

PubMed

McGinnis, Patricia Quinn; Guenther, Lee Ann; Wainwright, Susan F

2016-09-01

The physical therapy profession has adopted professional core values, which define expected values for its members, and developed a self-assessment tool with sample behaviors for each of the 7 core values. However, evidence related to the integration of these core values into practice is limited. The aims of this study were: (1) to gain insight into physical therapists' development of professional core values and (2) to gain insight into participants' integration of professional core values into clinical practice. A qualitative design permitted in-depth exploration of the development and integration of the American Physical Therapy Association's professional core values into physical therapist practice. Twenty practicing physical therapists were purposefully selected to explore the role of varied professional, postprofessional, and continuing education experiences related to exposure to professional values. The Core Values Self-Assessment and résumé sort served as prompts for reflection via semistructured interviews. Three themes were identified: (1) personal values were the foundation for developing professional values, which were further shaped by academic and clinical experiences, (2) core values were integrated into practice independent of practice setting and varied career paths, and (3) participants described the following professional core values as well integrated into their practice: integrity, compassion/caring, and accountability. Social responsibility was an area consistently identified as not being integrated into their practice. The Core Values Self-Assessment tool is a consensus-based document developed through a Delphi process. Future studies to establish reliability and construct validity of the tool may be warranted. Gaining an in-depth understanding of how practicing clinicians incorporate professional core values into clinical practice may shed light on the relationship between core values mastery and its impact on patient care. Findings may help shape educators' decisions for professional (entry-level), postprofessional, and continuing education. © 2016 American Physical Therapy Association.

Exploring the role of children's dreams in psychoanalytic practice today: a pilot study.

PubMed

Lempen, Olivia; Midgley, Nick

2006-01-01

The aim of this research study was to investigate the role of children's dreams in the practice of child psychoanalysis today, and to explore contemporary psychoanalytic understanding of children's dreams. This pilot study consisted of two stages. The first involved a document analysis of published articles in The Psychoanalytic Study of the Child, making a comparison between those of the early 1950s and the 1990s, in order to see in what way the discourse around children's dreams within the psychoanalytic literature has changed over time. The second stage, based on questionnaires and in-depth interviews, attempted to understand in more detail the way contemporary child analysts, working in the Anna Freudian tradition, think about dreams and use them in their clinical practice. Results suggest that there has been a decreased focus on dreams in a clinical context over time, and that this may partly be a consequence of changing theoretical models and changes in training. When work with dreams does take place, it appears that child analysts have

Assessing fidelity to evidence-based practices in usual care: the example of family therapy for adolescent behavior problems.

PubMed

Hogue, Aaron; Dauber, Sarah

2013-04-01

This study describes a multimethod evaluation of treatment fidelity to the family therapy (FT) approach demonstrated by front-line therapists in a community behavioral health clinic that utilized FT as its routine standard of care. Study cases (N=50) were adolescents with conduct and/or substance use problems randomly assigned to routine family therapy (RFT) or to a treatment-as-usual clinic not aligned with the FT approach (TAU). Observational analyses showed that RFT therapists consistently achieved a level of adherence to core FT techniques comparable to the adherence benchmark established during an efficacy trial of a research-based FT. Analyses of therapist-report measures found that compared to TAU, RFT demonstrated strong adherence to FT and differentiation from three other evidence-based practices: cognitive-behavioral therapy, motivational interviewing, and drug counseling. Implications for rigorous fidelity assessments of evidence-based practices in usual care settings are discussed. Copyright © 2012 Elsevier Ltd. All rights reserved.

NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population.

PubMed

Burks, A Wesley; Jones, Stacie M; Boyce, Joshua A; Sicherer, Scott H; Wood, Robert A; Assa'ad, Amal; Sampson, Hugh A

2011-11-01

Data from many studies have suggested a rise in the prevalence of food allergies during the past 10 to 20 years. Currently, no curative treatments for food allergy exist, and there are no effective means of preventing the disease. Management of food allergy involves strict avoidance of the allergen in the patient's diet and treatment of symptoms as they arise. Because diagnosis and management of the disease can vary between clinical practice settings, the National Institute of Allergy and Infectious Diseases (NIAID) sponsored development of clinical guidelines for the diagnosis and management of food allergy. The guidelines establish consensus and consistency in definitions, diagnostic criteria, and management practices. They also provide concise recommendations on how to diagnose and manage food allergy and treat acute food allergy reactions. The original guidelines encompass practices relevant to patients of all ages, but food allergy presents unique and specific concerns for infants, children, and teenagers. To focus on those concerns, we describe here the guidelines most pertinent to the pediatric population.

Clinical interpretation of opioid tolerance versus opioid-induced hyperalgesia.

PubMed

Chen, Lucy; Sein, Michael; Vo, Trang; Amhmed, Shihab; Zhang, Yi; Hilaire, Kristin St; Houghton, Mary; Mao, Jianren

2014-01-01

Opioid analgesics are commonly used to manage moderate to severe pain. However, the long-term use of opioids could lead to opioid tolerance (OT) and opioid-induced hyperalgesia (OIH). Distinguishing OIH from OT would impact the practice of opioid therapy because opioid dose adjustment may differentially influence OT and OIH. Currently, there are no standard criteria of OT versus OIH causing considerable ambiguity in clinical interpretation and management of these conditions. The authors designed a practitioner-based survey consisting of 20 targeted questions. Answering these questions would require responders' actual clinical experiences with opioid therapy. The survey was conducted between 2011 and 2012 through direct mails or e-mails to 1,408 physicians who are currently practicing in the United States. The authors find that certain clinical characteristics (eg, increased pain despite opioid dose escalation) are often used by practitioners to make differential diagnosis of OT and OIH despite some overlap in their clinical presentation. A key difference in clinical outcome is that OT and OIH could be improved and exacerbated by opioid dose escalation, respectively. Our survey results revealed a significant knowledge gap in some responders regarding differential diagnosis and management of OT and OIH. The results also identified several issues, such as opioid dose adjustment and clinical comorbidities related to OT and OIH, which require future patient-based studies.

A survey of UK fertility clinics' approach to surrogacy arrangements.

PubMed

Norton, Wendy; Crawshaw, Marilyn; Hudson, Nicky; Culley, Lorraine; Law, Caroline

2015-09-01

This paper draws on the findings of the first survey of surrogacy arrangements in Human Fertilisation and Embryology Authority (HFEA) licensed fertility clinics since 1998. Given the complex social, ethical and legal issues involved, surrogacy continues to raise debate worldwide and fuel calls for increased domestic provision in developed countries. However, little is known about how recent changes have affected HFEA licensed clinics. A 24-item online survey was undertaken between August and October 2013, designed to improve understanding of recent trends and current practices associated with UK-based surrogacy, and consider the implications for future policy and practice in UK and cross-border surrogacy arrangements. The response rate was 51.4%, comprising 54 clinics. Quantitative data were analysed using descriptive statistics, and open-ended qualitative responses analysed for extending understanding. Of the participating clinics, 42.6% offered surrogacy (mostly gestational surrogacy). Heterosexual couples using gestational surrogacy were the largest group currently using services followed by male same-sex couples. Most clinics reported having encountered problems with surrogacy treatments, suggesting barriers still exist to expanding the UK provision of surrogacy arrangements. It is important that professionals are well informed about the legal implications of surrogacy and that clinics have consistent and appropriate operational protocols for surrogacy arrangements. Copyright © 2015 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

The ethical and pedagogical effects of modeling "not-so-universal" precautions.

PubMed

Aultman, Julie M; Borges, Nicole J

2011-01-01

We sought to understand current medical students' levels of training and knowledge, and their attitudes regarding universal precautions practices and underlying professional and ethical issues. A total of 54 US medical students at two schools were interviewed to determine the level of understanding and training students receive about universal precautions, their feelings about the effectiveness (or ineffectiveness) of universal precautions, the frequency and kinds of universal precautions used by healthcare professionals as observed by medical students, and students' perspectives about the lack of or inconsistent use of universal precautions. Pre-clinical students focused on safe-sex practices among students and professionals, as well as simple, important acts to protect oneself against infection and disease, such as hand-washing. Clinical students, on the other hand, had more exposure to observing and practicing universal precautions, thus presented us with more, in-depth responses pertaining to inconsistent and ineffective use of universal precautions among peers and role models. Several themes were noted from students' responses. This study confirms previously acquired data that universal precautions are not consistently or appropriately used by healthcare professionals, it is a significant and novel study in that it reveals a hidden, ethical, and clinical problem in medical education.

Building a pediatric neurocritical care program: a multidisciplinary approach to clinical practice and education from the intensive care unit to the outpatient clinic.

PubMed

Wainwright, Mark S; Grimason, Michele; Goldstein, Joshua; Smith, Craig M; Amlie-Lefond, Catherine; Revivo, Gadi; Noah, Zehava L; Harris, Zena L; Epstein, Leon G

2014-12-01

We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Workplace safety and health for the veterinary health care team.

PubMed

Gibbins, John D; MacMahon, Kathleen

2015-03-01

Veterinary clinic employers have a legal and ethical responsibility to provide a safe and healthy workplace. Clinic members are responsible for consistently using safe practices and procedures set up by their employer. Development and implementation of a customized comprehensive workplace safety and health program is emphasized, including an infection control plan. Occupational safety and health regulations are reviewed. The hazards of sharps, animal bites and scratches, and drugs are discussed. Strategies to prevent or minimize adverse health effects and resources for training and education are provided. Published by Elsevier Inc.

Clinical signs of pancreatitis.

PubMed

Penny, Steven M

2012-01-01

The pancreas consists of complex structures that perform vital functions. Radiologic technologists must comprehend its normal structure and function to perform functional imaging procedures in their daily practice, as well as to know how any deviation from normalcy can disrupt homeostasis. Because pancreatitis is a potentially life-threatening disease, a thorough understanding of the clinical manifestation and imaging characteristics of the various forms of the disease is crucial. This article reviews distinctive pancreatic function and discusses basic pancreas imaging. In addition, acute and chronic pancreatitis is explored, including the role of medical imaging in its diagnosis, complications, and prognosis.

A practical method to standardise and optimise the Philips DoseRight 2.0 CT automatic exposure control system.

PubMed

Wood, T J; Moore, C S; Stephens, A; Saunderson, J R; Beavis, A W

2015-09-01

Given the increasing use of computed tomography (CT) in the UK over the last 30 years, it is essential to ensure that all imaging protocols are optimised to keep radiation doses as low as reasonably practicable, consistent with the intended clinical task. However, the complexity of modern CT equipment can make this task difficult to achieve in practice. Recent results of local patient dose audits have shown discrepancies between two Philips CT scanners that use the DoseRight 2.0 automatic exposure control (AEC) system in the 'automatic' mode of operation. The use of this system can result in drifting dose and image quality performance over time as it is designed to evolve based on operator technique. The purpose of this study was to develop a practical technique for configuring examination protocols on four CT scanners that use the DoseRight 2.0 AEC system in the 'manual' mode of operation. This method used a uniform phantom to generate reference images which form the basis for how the AEC system calculates exposure factors for any given patient. The results of this study have demonstrated excellent agreement in the configuration of the CT scanners in terms of average patient dose and image quality when using this technique. This work highlights the importance of CT protocol harmonisation in a modern Radiology department to ensure both consistent image quality and radiation dose. Following this study, the average radiation dose for a range of CT examinations has been reduced without any negative impact on clinical image quality.

Clinical supervision in the emergency department: a critical incident study

PubMed Central

Kilroy, D A

2006-01-01

Objectives To identify the key features of effective clinical supervision in the emergency department (ED) from the perspectives of enthusiastic consultants and specialist registrars. To highlight the importance of clinical supervision within emergency medicine, and identify obstructions to its occurrence in everyday practice. Methods A critical incident study was undertaken consisting of structured interviews, conducted by telephone or in person, with 18 consultants and higher level trainees selected for their interest in supervision. Results Direct clinical supervision of key practical skills and patient management steps was considered to be of paramount importance in providing quality patient care and significantly enhancing professional confidence. The adequacy of supervision varied depending upon patient presentation. Trainees were concerned with the competence and skills of their supervisor; consultants were concerned with wider systemic constraints upon the provision of adequate supervision to juniors. Conclusions The value of supervision extends to all patient presentations in the ED. The study raised questions concerning the appropriate attitudes and qualifications for supervisors. Protected supervisory time for those with trainees is mandatory, and must be incorporated within ED consultant job planning. PMID:16439737

An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial.

PubMed

Maas, Marjo J M; van der Wees, Philip J; Braam, Carla; Koetsenruijter, Jan; Heerkens, Yvonne F; van der Vleuten, Cees P M; Nijhuis-van der Sanden, Maria W G

2015-04-01

Clinical practice guidelines (CPGs) are not readily implemented in clinical practice. One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs. Peer assessment (PA) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice, awareness of professional performance, and attainment of personal goals. The purpose of this study was to compare the effectiveness of PA with the usual case discussion (CD) strategy on adherence to CPGs for physical therapist management of upper extremity complaints. A single-masked, cluster-randomized controlled trial with pretest-posttest design was conducted. Twenty communities of practice (n=149 physical therapists) were randomly assigned to groups receiving PA or CD, with both interventions consisting of 4 sessions over 6 months. Both PA and CD groups worked on identical clinical cases relevant to the guidelines. Peer assessment focused on individual performance observed and evaluated by peers; CD focused on discussion. Guideline adherence was measured with clinical vignettes, reflective practice was measured with the Self-Reflection and Insight Scale (SRIS), awareness of performance was measured via the correlation between perceived and assessed improvement, and attainment of personal goals was measured with written commitments to change. The PA groups improved more on guideline adherence compared with the CD groups (effect=22.52; 95% confidence interval [95% CI]=2.38, 42.66; P=.03). The SRIS scores did not differ between PA and CD groups. Awareness of performance was greater for the PA groups (r=.36) than for the CD groups (r=.08) (effect=14.73; 95% CI=2.78, 26.68; P=.01). The PA strategy was more effective than the CD strategy in attaining personal goals (effect=0.50; 95% CI=0.04, 0.96; P=.03). Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study. Peer assessment was more effective than CD in improving adherence to CPGs. Personal feedback may have contributed to its effectiveness. Future research should address the role of the group coach. © 2015 American Physical Therapy Association.

Predictors of consistent condom use among Portuguese women attending family planning clinics.

PubMed

Costa, Eleonora C V; Oliveira, Rosa; Ferreira, Domingos; Pereira, M Graça

2016-01-01

Women account for 30% of all AIDS cases reported to the Health Ministry in Portugal and most infections are acquired through unprotected heterosexual sex with infected partners. This study analyzed socio-demographic and psychosocial predictors of consistent condom use and the role of education as a moderator variable among Portuguese women attending family planning clinics. A cross-sectional study using interviewer-administered fully structured questionnaires was conducted among 767 sexually active women (ages 18-65). Logistic regression analyses were used to explore the association between consistent condom use and the predictor variables. Overall, 78.7% of the women were inconsistent condom users. The results showed that consistent condom use was predicted by marital status (being not married), having greater perceptions of condom negotiation self-efficacy, having preparatory safer sexual behaviors, and not using condoms only when practicing abstinence. Living with a partner and having lack of risk perception significantly predicted inconsistent condom use. Less educated women were less likely to use condoms even when they perceive being at risk. The full model explained 53% of the variance in consistent condom use. This study emphasizes the need for implementing effective prevention interventions in this population showing the importance of taking education into consideration.

Structured data quality reports to improve EHR data quality.

PubMed

Taggart, Jane; Liaw, Siaw-Teng; Yu, Hairong

2015-12-01

To examine whether a structured data quality report (SDQR) and feedback sessions with practice principals and managers improve the quality of routinely collected data in EHRs. The intervention was conducted in four general practices participating in the Fairfield neighborhood electronic Practice Based Research Network (ePBRN). Data were extracted from their clinical information systems and summarised as a SDQR to guide feedback to practice principals and managers at 0, 4, 8 and 12 months. Data quality (DQ) metrics included completeness, correctness, consistency and duplication of patient records. Information on data recording practices, data quality improvement, and utility of SDQRs was collected at the feedback sessions at the practices. The main outcome measure was change in the recording of clinical information and level of meeting Royal Australian College of General Practice (RACGP) targets. Birth date was 100% and gender 99% complete at baseline and maintained. DQ of all variables measured improved significantly (p<0.01) over 12 months, but was not sufficient to comply with RACGP standards. Improvement was greatest with allergies. There was no significant change in duplicate records. SDQRs and feedback sessions support general practitioners and practice managers to focus on improving the recording of patient information. However, improved practice DQ, was not sufficient to meet RACGP targets. Randomised controlled studies are required to evaluate strategies to improve data quality and any associated improved safety and quality of care. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping

PubMed Central

2011-01-01

Background The goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States. Methods Participants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data. Results A total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups. Conclusions EBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light. PMID:21899754

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping.

PubMed

Green, Amy E; Aarons, Gregory A

2011-09-07

The goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States. Participants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data. A total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups. EBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light.

Drugs Used for Parenteral Sedation in Dental Practice

PubMed Central

Dionne, Raymond A.; Gift, Helen C.

1988-01-01

The relative efficacy and safety of drugs and combinations used clinically in dentistry as premedicants to alleviate patient apprehension are largely unsubstantiated. To evaluate the efficacy and safety of agents used for parenteral sedation through controlled clinical trials, it is first necessary to identify which drugs, doses, and routes of administration are actually used in practice. A survey instrument was developed to characterize the drugs used clinically for anesthesia and sedation by dentists with advanced training in pain control. A random sample of 500 dentists who frequently use anesthesia and sedation in practice was selected from the Fellows of the American Dental Society of Anesthesiology. The first mailing was followed by a second mailing to nonrespondents after 30 days. The respondents report a variety of parenteral sedation techniques in combination with local anesthesia (the response categories are not mutually exclusive): nitrous oxide (64%), intravenous conscious sedation (59%), intravenous “deep” sedation (47%), and outpatient general anesthesia (27%). Drugs most commonly reported for intravenous sedation include diazepam, methohexital, midazolam, and combinations of these drugs with narcotics. A total of 82 distinct drugs and combinations was reported for intravenous sedation and anesthesia. Oral premedication and intramuscular sedation are rarely used by this group. Most general anesthesia reported is done on an outpatient basis in private practice. These results indicate that a wide variety of drugs is employed for parenteral sedation in dental practice, but the most common practice among dentists with advanced training in anesthesia is local anesthesia supplemented with intravenous sedation consisting of a benzodiazepine and an opioid or a barbiturate. PMID:3250279

Medical students' attitudes towards early clinical exposure in Iran.

PubMed

Khabaz Mafinejad, Mahboobeh; Mirzazadeh, Azim; Peiman, Soheil; Khajavirad, Nasim; Mirabdolhagh Hazaveh, Mojgan; Edalatifard, Maryam; Allameh, Seyed-Farshad; Naderi, Neda; Foroumandi, Morteza; Afshari, Ali; Asghari, Fariba

2016-06-19

This study was carried out to investigate the medical students' attitudes towards early clinical exposure at Tehran University of Medical Sciences. A cross-sectional study was conducted during 2012-2015. A convenience sample of 298 first- and second-year students, enrolled in the undergraduate medical curriculum, participated in an early clinical exposure program. To collect data from medical students, a questionnaire consisting of open-ended questions and structured questions, rated on a five-point Likert scale, was used to investigate students' attitudes toward early clinical exposure. Of the 298 medical students, 216 (72%) completed the questionnaires. The results demonstrated that medical students had a positive attitude toward early clinical exposure. Most students (80.1%) stated that early clinical exposure could familiarize them with the role of basic sciences knowledge in medicine and how to apply this knowledge in clinical settings. Moreover, 84.5% of them believed that early clinical exposure increased their interest in medicine and encouraged them to read more. Furthermore, content analysis of the students' responses uncovered three main themes of early clinical exposure, were considered helpful to improve learning: "integration of theory and practice", "interaction with others and professional development" and "desire and motivation for learning medicine". Medical students found their first experience with clinical setting valuable. Providing clinical exposure in the initial years of medical curricula and teaching the application of basic sciences knowledge in clinical practice can enhance students' understanding of the role they will play in the future as a physician.

Implementation and outcomes of an evidence-based precepting program for burn nurses.

PubMed

Robbins, Johnnie R; Valdez-Delgado, Krystal K; Caldwell, Nicole W; Yoder, Linda H; Hayes, Elizabeth J; Barba, Michaèl G; Greeley, Hope L; Mitchell, Colleen; Mann-Salinas, Elizabeth A

2017-11-01

There is significant nationwide interest in transitioning new and new-to-specialty nurses into practice, especially in burn care. Lack of a structured transition program in our Burn Center was recognized as a contributing factor for nursing dissatisfaction and increased turnover compared to other hospital units. Employee evaluations exposed a need for more didactic instruction, hands-on learning, and preceptor support. The goal of this project was to implement an evidence-based transition to practice program specific to the burn specialty. The Iowa Model of Evidence-based Practice served as the model for this project. A working group was formed consisting of nurse scientists, clinical nurse leaders, clinical nurse specialists, lead preceptors, staff nurse preceptors and wound care coordinators. A systematic review of the literature was conducted focusing on nurse transition; preceptor development and transitioning nurse training programs with competency assessment, ongoing multifaceted evaluation and retention strategies were created. The evidence-based Vermont Nurses in Partnership (VNIP) Clinical Transition Framework was selected and subsequent education was provided to all Burn Center leaders and staff. Benchmarks for basic knowledge assessment (BKAT) and burn wound care were established among current staff by work site and education level to help evaluate transitioning nurses. Policies were modified to count each preceptor/transitioning nurse dyad as half an employee on the schedule. Multiple high-fidelity simulation scenarios were created to expand hands-on opportunities. From September 2012-December 2013, 110 (57% acute care nursing) Burn Center staff attended the VNIP Clinical Coaching Course, to include 34 interdisciplinary staff (rehabilitation, education, respiratory therapy, and outpatient clinic staff) and 100% of identified preceptors (n=33). A total of 30 new nurses participated in the transition program: 26 (87%) completed, 3 (10%) did not complete, and 1 (3%) received exception (no patient care). Transitioning nurses achieved passing BKAT scores (n=22; 76%) and WC scores (n=24; 93%); individual remediation was provided for those failing to achieve unit benchmarks and transition training was modified to improve areas of weakness. Transitioning nurses' weekly competency progression average initial ratings on a 10 point scale (10 most competent) were 5±2; final ratings averaged 9±1 (n=25) (p<0.0001). An evidence-based team practice approach toward preceptorship created a standardized, comprehensive and flexible precepting program to assist and support transition to specialty burn practice for experienced nurses. Use of objective metrics enabled ongoing assessment and made training adaptable, individualized, and cost effective. Application of this standardized approach across our organization may improve consistency for all transitions in practice specialty. Copyright © 2017. Published by Elsevier Ltd.

Enabling student placement through strategic partnerships between a health-care organization and tertiary institutions.

PubMed

Henderson, Amanda; Heel, Alison; Twentyman, Michelle

2007-01-01

Nursing management needs to demonstrate its commitment to clinical education for undergraduate nursing students. The vision for the nursing leadership and management team at Princess Alexandra Hospital is to guide and support the development of hospital clinicians, at all levels in the organization, to effectively facilitate undergraduate students' learning during their clinical practical experiences. This paper examines the evolution of the meaning, commitment and practices that have been intrinsic to the development of strategic partnerships between the health-care organization and tertiary institutions to ensure that hospital staff who consistently facilitate student learning in the clinical context are well supported. The partnerships are based on open channels of communication between the health-care organization and the tertiary institutions whereby each party identifies its needs and priorities. This has resulted in increased hospital staff satisfaction through greater involvement by them in the placements of students, and enhanced understanding of clinicians of the student placement process that has contributed to improved satisfaction and outcomes for the students.

Reflective Journaling for Critical Thinking Development in Advanced Practice Registered Nurse Students.

PubMed

Raterink, Ginger

2016-02-01

Critical thinking, clinical decision making, and critical reflection have been identified as skills required of nurses in every clinical situation. The Educating Nurses: A Call for Radical Transformation report suggested that critical reflection is a key to improving the educational process. Reflective journaling is a tool that helps develop such skills. This article presents the tool of reflective journaling and the use of this process by educators working with students. It describes the use of reflective journaling in graduate nursing education, as well as a scoring process to evaluate the reflection and provide feedback. Students and faculty found the journaling to be helpful for reflection of a clinical situation focused on critical thinking skill development. The rubric scoring tool provided faculty with a method for feedback. Reflective journaling is a tool that faculty and students can use to develop critical thinking skills for the role of the advanced practice RN. A rubric scoring system offers a consistent format for feedback. Copyright 2016, SLACK Incorporated.

Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines.

PubMed

Simons, M; King, S; Edgar, D

2003-01-01

Clinical practice guidelines are a tool to assist with clinical decision making. They provide information about the care for a condition and make recommendations based on research evidence, which can be adapted locally. A focus group within the Allied Health Interest Group of the Australian and New Zealand Burn Association has compiled the "Occupational Therapy and Physiotherapy for the Patient with Burns--Principles and Management Guidelines." These guidelines are designed as a practical guide to the relevant clinical knowledge and therapy intervention techniques required for effective patient management. Content areas include respiratory management, edema management, splinting and positioning, physical function (mobility, function, exercise), scar management, and psychosocial and mutual elements. The document has undergone extensive review by members of the Australian and New Zealand Burn Association to ensure clarity, internal consistency, and acceptability. The guidelines have been endorsed by the Australian and New Zealand Burn Association. An abridged version of the guidelines is included in this article, with the full document available from www.anzba.org.au.

Clinical Audit of the Radiotherapy Process in Rectal Cancer: Clinical Practice Guidelines and Quality Certification Do Not Avert Variability in Clinical Practice.

PubMed

Torras, M G; Canals, E; Jurado-Bruggeman, D; Marín-Borras, S; Macià, M; Jové, J; Boladeras, A M; Muñoz-Montplet, C; Molero, J; Picón, C; Puigdemont, M; Aliste, L; Torrents, A; Guedea, F; Borras, J M

2018-06-01

The therapeutic approach to cancer is complex and multidisciplinary. Radiotherapy is among the essential treatments, whether used alone or in conjunction with other therapies. This study reports a clinical audit of the radiotherapy process to assess the process of care, evaluate adherence to agreed protocols and measure the variability to improve therapeutic quality for rectal cancer. Multicentre retrospective cohort study in a representative sample of patients diagnosed with rectal cancer in the Institut Català d'Oncologia, a comprehensive cancer centre with three different settings. We developed a set of indicators to assess the key areas of the radiotherapy process. The clinical audit consisted of a review of a random sample of 40 clinical histories for each centre. The demographic profile, histology and staging of patients were similar between centres. The MRI reports did not include the distance from tumour to mesorectal fascia (rCRM) in 38.3% of the cases. 96.7% of patients received the planned dose, and 57.4% received it at the planned time. Surgery followed neoadjuvant treatment in 96.7% of the patients. Among this group, postoperative CRM was recorded in 65.5% of the cases and was negative in 93.4% of these. With regard to the 34.5% (n = 40) of cases where no CRM value was stated, there were differences between the centres. Mean follow-up was 3.4 (SD 0.6) years, and overall survival at four years was 81.7%. The audit revealed a suboptimal degree of adherence to clinical practice guidelines. Significant variability between centres exists from a clinical perspective but especially with regard to organization and process. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Clinical psychologists' experiences of reflective staff groups in inpatient psychiatric settings: a mixed methods study.

PubMed

Heneghan, Cara; Wright, John; Watson, Gilli

2014-01-01

Background Reflective practice groups have been recommended for improving staff wellbeing and team functioning in inpatient psychiatric services, and clinical psychologists have been identified as potential leaders in this type of work. Research is limited with little information about reflective practice group guidelines, prevalence and effectiveness. Aims The aims of this study were to describe clinical psychologists' practice in reflective groups for staff in inpatient psychiatric services and to explore how such groups are conceptualized and implemented. Methods Online questionnaires and follow-up interviews were used to gain broad descriptions of practice and in-depth information about participants' experiences. The sample consisted of 73 clinical psychologists working in the UK, six of whom were interviewed. Data were analysed using descriptive statistics, content analysis and thematic analysis. Results Clinical psychologists regularly facilitate reflective staff groups in inpatient psychiatric settings in the UK. Common outcomes related to staff wellbeing, service culture and teamwork. Engagement, group dynamics and lack of management support were common challenges. Group experiences were influenced by the organizational context. Conclusions Clinical psychologists' practices regarding reflective staff groups were in line with recent professional developments. Several difficulties were described, which may be indicative of both a difficulty inherent to the task and a training gap in reflective staff group process. The study had methodological limitations but offers a useful contribution to the literature, and enables practice and training implications to be drawn. The need for further research exploring facilitator characteristics, views of group participants and the impact of reflective staff groups on patients is indicated. The term 'reflective practice group' encompasses a range of practices, but a typical group structure was found with common aims, outcomes and challenges. Reflective staff groups are regularly facilitated by clinical psychologists in inpatient psychiatric settings in the UK and are influenced by practitioner experience as well as psychodynamic, systemic and group process theories. The safety required for reflective groups to function is influenced by the organizational context, and groups can contribute to shifts in culture toward including psychosocial perspectives. Reflective staff groups represent one type of contribution to an inpatient psychiatric service and team relationships; other processes to encourage alternative professional perspectives and values might also support change. More research is recommended to explore facilitator characteristics, the views of staff teams on reflective staff groups and the impact of these groups on patients. Copyright © 2013 John Wiley & Sons, Ltd.

Decolonising medical curricula through diversity education: lessons from students.

PubMed

Nazar, Mahdi; Kendall, Kathleen; Day, Lawrence; Nazar, Hamde

2015-04-01

The General Medical Council (GMC) expects that medical students graduate with an awareness of how the diversity of the patient population may affect health outcomes and behaviours. However, little guidance has been provided on how to incorporate diversity teaching into medical school curricula. Research highlights the existence of two different models within medical education: cultural competency and cultural humility. The Southampton medical curriculum includes both models in its diversity teaching, but little was known about which model was dominant or about the students' experience. Fifteen semi-structured, in-depth interviews were carried out with medical students at the University of Southampton. Data were analysed thematically using elements of grounded theory and constant comparison. Students identified early examples of diversity teaching consistent with a cultural humility approach. In later years, the limited diversity teaching recognised by students generally adopted a cultural competency approach. Students tended to perceive diversity as something that creates problems for healthcare professionals due to patients' perceived differences. They also reported witnessing a number of questionable practices related to diversity issues that they felt unable to challenge. The dissonance created by differences in the largely lecture based and the clinical environments left students confused and doubting the value of cultural humility in a clinical context. Staff training on diversity issues is required to encourage institutional buy-in and establish consistent educational and clinical environments. By tackling cultural diversity within the context of patient-centred care, cultural humility, the approach students valued most, would become the default model. Reflective practice and the development of a critical consciousness are crucial in the improvement of cultural diversity training and thus should be facilitated and encouraged. Educators can adopt a bidirectional mode of teaching and work with students to decolonise medical curricula and improve medical practice.

The impact of decision aids to enhance shared decision making for diabetes (the DAD study): protocol of a cluster randomized trial.

PubMed

LeBlanc, Annie; Ruud, Kari L; Branda, Megan E; Tiedje, Kristina; Boehmer, Kasey R; Pencille, Laurie J; Van Houten, Holly; Matthews, Marc; Shah, Nilay D; May, Carl R; Yawn, Barbara P; Montori, Victor M

2012-05-28

Shared decision making contributes to high quality healthcare by promoting a patient-centered approach. Patient involvement in selecting the components of a diabetes medication program that best match the patient's values and preferences may also enhance medication adherence and improve outcomes. Decision aids are tools designed to involve patients in shared decision making, but their adoption in practice has been limited. In this study, we propose to obtain a preliminary estimate of the impact of patient decision aids vs. usual care on measures of patient involvement in decision making, diabetes care processes, medication adherence, glycemic and cardiovascular risk factor control, and resource utilization. In addition, we propose to identify, describe, and explain factors that promote or inhibit the routine embedding of decision aids in practice. We will be conducting a mixed-methods study comprised of a cluster-randomized, practical, multicentered trial enrolling clinicians and their patients (n = 240) with type 2 diabetes from rural and suburban primary care practices (n = 8), with an embedded qualitative study to examine factors that influence the incorporation of decision aids into routine practice. The intervention will consist of the use of a decision aid (Statin Choice and Aspirin Choice, or Diabetes Medication Choice) during the clinical encounter. The qualitative study will include analysis of video recordings of clinical encounters and in-depth, semi-structured interviews with participating patients, clinicians, and clinic support staff, in both trial arms. Upon completion of this trial, we will have new knowledge about the effectiveness of diabetes decision aids in these practices. We will also better understand the factors that promote or inhibit the successful implementation and normalization of medication choice decision aids in the care of chronic patients in primary care practices. NCT00388050.

The American Academy of Clinical Neuropsychology, National Academy of Neuropsychology, and Society for Clinical Neuropsychology (APA Division 40) 2015 TCN Professional Practice and 'Salary Survey': Professional Practices, Beliefs, and Incomes of U.S. Neuropsychologists.

PubMed

Sweet, Jerry J; Benson, Laura M; Nelson, Nathaniel W; Moberg, Paul J

2015-01-01

The current survey updated professional practice and income information pertaining to clinical neuropsychology. Doctoral-level members of the American Academy of Clinical Neuropsychology, Division 40 (Clinical Neuropsychology) of the American Psychological Association, and the National Academy of Neuropsychology and other neuropsychologists, as well as postdoctoral trainees in the Association of Postdoctoral Programs in Clinical Neuropsychology and at other training sites were invited to participate in a web-based survey in early 2015. The sample of 1777 respondents, of whom 1579 were doctoral-level practitioners and 198 were postdoctoral trainees, was larger than the prior 2010 income and practice survey. The substantial proportional change in gender has continued, with women now a clear majority in the postdoctoral trainee sample as well as in the practitioner sample. Dissimilar from the median age trajectory of American Psychological Association members, the median age of clinical neuropsychologists remains essentially unchanged since 1989, indicating a substantial annual influx of young neuropsychologists. The question of whether the Houston Conference training model has become an important influence in the specialty can now be considered settled in the affirmative among postdoctoral trainees and practitioners. Testing assistant usage remains commonplace, and continues to be more common in institutions. The vast majority of clinical neuropsychologists work full-time and very few are unemployed and seeking employment. The numbers of neuropsychologists planning to retire in the coming 5-10 years do not suggest a "baby boomer" effect or an unexpected bolus of planned retirements in the next 10 years that would be large enough to be worrisome. Average length of time reported for evaluations appears to be increasing across time. The most common factors affecting evaluation length were identified, with the top three being: (1) goal of evaluation, (2) stamina/health of examinee, and (3) age of examinee. Pediatric specialists remain more likely than others to work part-time, more likely to work in institutions, report lower incomes than respondents with a lifespan professional identity, and are far more likely to be women. Incomes continue to vary considerably by years of clinical practice, work setting, amount of forensic practice, state, and region of country. Neurologists are the number one referral source in institutions and in private practice, as well as for pediatric, adult, and lifespan practitioners. Learning disability is no longer among the top five conditions seen by pediatric neuropsychologists; traumatic brain injury and seizure disorder are common reasons for clinical evaluations at all age ranges. There is a continued increase in forensic practice and a clear consensus on the use of validity testing. There is a substantial interest in subspecialization board certification, with the greatest interest evident among postdoctoral trainees. Income satisfaction, job satisfaction, and work-life balance satisfaction are higher for men. Job satisfaction varies across general work setting and across age range of practice. Work-life balance satisfaction is moderately correlated with income satisfaction and job satisfaction. Again in this five-year interval survey, a substantial majority of respondents reported increased incomes, despite experiencing substantial negative practice effects related to changes in the US health care system. Numerous breakdowns related to income and professional activities are provided. Professional practice survey information continues to provide valuable perspectives regarding consistency and change in the activities, beliefs, and incomes of US clinical neuropsychologists.

Aligning Documentation With Congenital Muscular Torticollis Clinical Practice Guidelines: Administrative Case Report.

PubMed

Gutierrez, Dennis; Kaplan, Sandra L

2016-01-01

A hospital-based pediatric outpatient center, wanting to weave evidence into practice, initiated an update of knowledge, skills, and documentation patterns with its staff physical therapists and occupational therapists who treat people with congenital muscular torticollis (CMT). This case report describes 2 cycles of implementation: (1) the facilitators and barriers to implementation and (2) selected quality improvement outcomes aligned with published clinical practice guidelines (CPGs). The Pediatric Therapy Services of St Joseph's Regional Medical Center in New Jersey has 4 full-time, 1 part-time, and 3 per diem staff. Chart audits in 2012 revealed variations in measurement, interventions, and documentation that led to quality improvement initiatives. An iterative process, loosely following the knowledge-to-action cycle, included a series of in-service training sessions to review the basic anatomy, pathokinesiology, and treatment strategies for CMT; reading assignments of the available CPGs; journal review; documentation revisions; and training on the recommended measurements to implement 2 published CPGs and measure outcomes. A previous 1-page generic narrative became a 3-page CMT-specific form aligned with the American Physical Therapy Association Section on Pediatrics CMT CPG recommendations. Staff training on the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, classification of severity, type of CMT, prognostication, measures of cervical range of motion, and developmental progression improved documentation consistency from 0% to 81.9% to 100%. Clinicians responded positively to using the longer initial evaluation form. Successful implementation of both clinical and documentation practices were facilitated by a multifaceted approach to knowledge translation that included a culture supportive of evidence-based practice, administrative support for training and documentation redesign, commitment by clinicians to embrace changes aimed at improved care, and clinical guidelines that provide implementable recommendations. © 2016 American Physical Therapy Association.

Assessment and revision of clinical pharmacy practice internet web sites.

PubMed

Edwards, Krystal L; Salvo, Marissa C; Ward, Kristina E; Attridge, Russell T; Kiser, Katie; Pinner, Nathan A; Gallegos, Patrick J; Kesteloot, Lori Lynn; Hylton, Ann; Bookstaver, P Brandon

2014-02-01

Health care professionals, trainees, and patients use the Internet extensively. Editable Web sites may contain inaccurate, incomplete, and/or outdated information that may mislead the public's perception of the topic. To evaluate the editable, online descriptions of clinical pharmacy and pharmacist and attempt to improve their accuracy. The authors identified key areas within clinical pharmacy to evaluate for accuracy and appropriateness on the Internet. Current descriptions that were reviewed on public domain Web sites included: (1) clinical pharmacy and the clinical pharmacist, (2) pharmacy education, (3) clinical pharmacy and development and provision for reimbursement, (4) clinical pharmacists and advanced specialty certifications/training opportunities, (5) pharmacists and advocacy, and (6) clinical pharmacists and interdisciplinary/interprofessional content. The authors assessed each content area to determine accuracy and prioritized the need for updating, when applicable, to achieve consistency in descriptions and relevancy. The authors found that Wikipedia, a public domain that allows users to update, was consistently the most common Web site produced in search results. The authors' evaluation resulted in the creation or revision of 14 Wikipedia Web pages. However, rejection of 3 proposed newly created Web pages affected the authors' ability to address identified content areas with deficiencies and/or inaccuracies. Through assessing and updating editable Web sites, the authors strengthened the online representation of clinical pharmacy in a clear, cohesive, and accurate manner. However, ongoing assessments of the Internet are continually needed to ensure accuracy and appropriateness.

Reliability and validity in a nutshell.

PubMed

Bannigan, Katrina; Watson, Roger

2009-12-01

To explore and explain the different concepts of reliability and validity as they are related to measurement instruments in social science and health care. There are different concepts contained in the terms reliability and validity and these are often explained poorly and there is often confusion between them. To develop some clarity about reliability and validity a conceptual framework was built based on the existing literature. The concepts of reliability, validity and utility are explored and explained. Reliability contains the concepts of internal consistency and stability and equivalence. Validity contains the concepts of content, face, criterion, concurrent, predictive, construct, convergent (and divergent), factorial and discriminant. In addition, for clinical practice and research, it is essential to establish the utility of a measurement instrument. To use measurement instruments appropriately in clinical practice, the extent to which they are reliable, valid and usable must be established.

A review of empirical research related to the use of small quantitative samples in clinical outcome scale development.

PubMed

Houts, Carrie R; Edwards, Michael C; Wirth, R J; Deal, Linda S

2016-11-01

There has been a notable increase in the advocacy of using small-sample designs as an initial quantitative assessment of item and scale performance during the scale development process. This is particularly true in the development of clinical outcome assessments (COAs), where Rasch analysis has been advanced as an appropriate statistical tool for evaluating the developing COAs using a small sample. We review the benefits such methods are purported to offer from both a practical and statistical standpoint and detail several problematic areas, including both practical and statistical theory concerns, with respect to the use of quantitative methods, including Rasch-consistent methods, with small samples. The feasibility of obtaining accurate information and the potential negative impacts of misusing large-sample statistical methods with small samples during COA development are discussed.

Development and evaluation of online evidence based guideline bank system.

PubMed

Park, Myonghwa

2006-01-01

The purpose of this study was to develop and evaluate the online evidence-based nursing practice guideline bank system to support the best evidence-based decision in the clinical and community practice settings. The main homepage consisted of seven modules for introduction of site, EBN, guideline bank, guideline development, guideline review, related sites, and community. The major contents in the guidelines were purpose, developer, intended audience, method of development, target population, testing, knowledge components, and evaluation. Electronic versions of the guidelines were displayed by XML, PDF, and PDA versions. The system usability were evaluated by general users, guideline developers, and guideline reviewers on the web and the results showed high scores of satisfaction. This online evidence-based guideline bank system could support nurses' best and cost-effective clinical decision using the sharable standardized guidelines with education module of evidence based nursing.

Formal and Informal Continuing Education Activities and Athletic Training Professional Practice

PubMed Central

Armstrong, Kirk J.; Weidner, Thomas G.

2010-01-01

Abstract Context: Continuing education (CE) is intended to promote professional growth and, ultimately, to enhance professional practice. Objective: To determine certified athletic trainers' participation in formal (ie, approved for CE credit) and informal (ie, not approved for CE credit) CE activities and the perceived effect these activities have on professional practice with regard to improving knowledge, clinical skills and abilities, attitudes toward patient care, and patient care itself. Design: Cross-sectional study. Setting: Athletic training practice settings. Patients or Other Participants: Of a geographic, stratified random sample of 1000 athletic trainers, 427 (42.7%) completed the survey. Main Outcome Measure(s): The Survey of Formal and Informal Athletic Training Continuing Education Activities was developed and administered electronically. The survey consisted of demographic characteristics and Likert-scale items regarding CE participation and perceived effect of CE on professional practice. Internal consistency of survey items was determined using the Cronbach α (α  =  0.945). Descriptive statistics were computed for all items. An analysis of variance and dependent t tests were calculated to determine differences among respondents' demographic characteristics and their participation in, and perceived effect of, CE activities. The α level was set at .05. Results: Respondents completed more informal CE activities than formal CE activities. Participation in informal CE activities included reading athletic training journals (75.4%), whereas formal CE activities included attending a Board of Certification–approved workshop, seminar, or professional conference not conducted by the National Athletic Trainers' Association or affiliates or committees (75.6%). Informal CE activities were perceived to improve clinical skills or abilities and attitudes toward patient care. Formal CE activities were perceived to enhance knowledge. Conclusions: More respondents completed informal CE activities than formal CE activities. Both formal and informal CE activities were perceived to enhance athletic training professional practice. Informal CE activities should be explored and considered for CE credit. PMID:20446842

Safety of ranibizumab in routine clinical practice: 1-year retrospective pooled analysis of four European neovascular AMD registries within the LUMINOUS programme.

PubMed

Holz, Frank G; Bandello, Francesco; Gillies, Mark; Mitchell, Paul; Osborne, Aaron; Sheidow, Tom; Souied, Eric; Figueroa, Marta S

2013-09-01

Evaluation of 1-year safety profile of intravitreal ranibizumab 0.5 mg in neovascular age-related macular degeneration (NV-AMD) within routine clinical practice. The LUMINOUS programme comprises a prospective observational study assessing ranibizumab 'real-world' safety and clinical effectiveness across licensed indications worldwide and an annual retrospective pooled safety analysis from completed NV-AMD ranibizumab registries. 1-year data from four European registries are available. This retrospective pooled safety analysis assessed 1-year incidence rates for safety events of particular interest (key ocular or systemic events possibly related to the injection procedure or vascular endothelial growth factor inhibition) together with treatment exposure. Patients were treated according to local protocols within the ranibizumab licence. Data of 4444 patients from registries in Germany (n=3470), the Netherlands (n=243), Belgium (n=260) and Sweden (n=471) were retrospectively pooled. Between 70.4% and 84.4% of enrolled patients completed 1 year of follow-up. Most frequent overall ocular events of particular interest were retinal pigment epithelial tears (27 patients; <1%) and intraocular pressure-related events (12 patients; <0.3%). Most frequent non-ocular event of particular interest was stroke (19 patients; 0.4%); annual incidence of stroke was low across all registries (0.0-0.5%). Ranibizumab demonstrated favourable 1-year safety profile for NV-AMD in this routine clinical practice sample, consistent with previous reported trial data. Additional data from a larger patient population are needed to better describe the long-term safety profile of ranibizumab in routine clinical practice and further evaluate risk for infrequent but serious events in 'real-life' settings. The 5-year LUMINOUS prospective observational study will address this need.

Safety of ranibizumab in routine clinical practice: 1-year retrospective pooled analysis of four European neovascular AMD registries within the LUMINOUS programme

PubMed Central

Holz, Frank G; Bandello, Francesco; Gillies, Mark; Mitchell, Paul; Osborne, Aaron; Sheidow, Tom; Souied, Eric; Figueroa, Marta S

2013-01-01

Purpose Evaluation of 1-year safety profile of intravitreal ranibizumab 0.5 mg in neovascular age-related macular degeneration (NV-AMD) within routine clinical practice. Methods The LUMINOUS programme comprises a prospective observational study assessing ranibizumab ‘real-world’ safety and clinical effectiveness across licensed indications worldwide and an annual retrospective pooled safety analysis from completed NV-AMD ranibizumab registries. 1-year data from four European registries are available. This retrospective pooled safety analysis assessed 1-year incidence rates for safety events of particular interest (key ocular or systemic events possibly related to the injection procedure or vascular endothelial growth factor inhibition) together with treatment exposure. Patients were treated according to local protocols within the ranibizumab licence. Results Data of 4444 patients from registries in Germany (n=3470), the Netherlands (n=243), Belgium (n=260) and Sweden (n=471) were retrospectively pooled. Between 70.4% and 84.4% of enrolled patients completed 1 year of follow-up. Most frequent overall ocular events of particular interest were retinal pigment epithelial tears (27 patients; <1%) and intraocular pressure-related events (12 patients; <0.3%). Most frequent non-ocular event of particular interest was stroke (19 patients; 0.4%); annual incidence of stroke was low across all registries (0.0–0.5%). Conclusions Ranibizumab demonstrated favourable 1-year safety profile for NV-AMD in this routine clinical practice sample, consistent with previous reported trial data. Additional data from a larger patient population are needed to better describe the long-term safety profile of ranibizumab in routine clinical practice and further evaluate risk for infrequent but serious events in ‘real-life’ settings. The 5-year LUMINOUS prospective observational study will address this need. PMID:23850682

Reflections on clinical practice whilst developing a portfolio of evidence: Perceptions of undergraduate nursing students in the Western Cape, South Africa.

PubMed

Ticha, Victoire; Fakude, Lorraine P

2015-12-09

In order to develop clinical judgement, nurses should be encouraged to become analytical and critical thinkers. Development of a portfolio of evidence (PoE) of reflection on clinical experiences is one of the strategies that can be used to enhance analytical and critical thinking amongst nursing students. Students' perceptions of the process are important in order to encourage their reflective practice. PoE compilation at a school of nursing at a university in the Western Cape includes evidence of students' clinical learning which they present in a portfolio. The students are expected to reflect on their clinical learning experiences and include these reflections in their portfolios. To describe the perceptions of fourth-year nursing students regarding reflective practice whilst compiling their PoEs. A qualitative design was used to explore the perceptions of registered fourth-year nursing students with regard to their reflective practice whilst compiling their PoEs. Purposive sampling was used for selection of participants. Three focus group discussions were held, each consisting of six to eight participants. Data saturation was reached during the third meeting. Tesch's method of data analysis was used. Findings revealed that reflection enabled the learners to gain experience and identify challenges related to the expected events and tasks carried out at the hospitals and in the classroom whilst developing their PoE. The compilation of a PoE was a good teaching and learning strategy, and the skills, experience and knowledge that the participants in this study acquired boosted their self-esteem, confidence and critical thinking. Reflection also assisted in self-directed learning.

Quality requirements for EHR archetypes.

PubMed

Kalra, Dipak; Tapuria, Archana; Austin, Tony; De Moor, Georges

2012-01-01

The realisation of semantic interoperability, in which any EHR data may be communicated between heterogeneous systems and fully understood by computers as well as people on receipt, is a challenging goal. Despite the use of standardised generic models for the EHR and standard terminology systems, too much optionality and variability exists in how particular clinical entries may be represented. Clinical archetypes provide a means of defining how generic models should be shaped and bound to terminology for specific kinds of clinical data. However, these will only contribute to semantic interoperability if libraries of archetypes can be built up consistently. This requires the establishment of design principles, editorial and governance policies, and further research to develop ways for archetype authors to structure clinical data and to use terminology consistently. Drawing on several years of work within communities of practice developing archetypes and implementing systems from them, this paper presents quality requirements for the development of archetypes. Clinical engagement on a wide scale is also needed to help grow libraries of good quality archetypes that can be certified. Vendor and eHealth programme engagement is needed to validate such archetypes and achieve safe, meaningful exchange of EHR data between systems.

[Clinical application evaluation of Guidelines for the Diagnosis and Treatment of Common Diseases of Pediatrics in Traditional Chinese Medicine].

PubMed

Liu, Meng-Yu; Yang, Wei; Wang, Li-Ying; Zhao, Xue-Yao; Wang, Yue-Xi; Liu, Yu-Qi; Han, Xue-Jie; Lv, Ai-Ping

2017-09-01

Clinical application evaluation research of Guidelines for the Diagnosis and Treatment of Common Diseases of Pediatrics in Traditional Chinese Medicine intends to evaluate the quality level and clinical application of the guideline. A questionnaire and prospective case survey methods were used to evaluate the applicability evaluation based on the clinician questionnaire and the application evaluation based on clinical case observation. The applicability evaluation, familiarity and utilization rate of doctors' guidelines were 85.06%, 62.76%; Sort by technical grade, intermediate grade doctors have a higher familiarity rate and utilization rate, while the junior grade doctor's is lower; Guide quality level of applicability evaluation, other items' rational percentage are better than 96% except the items of health preserving and prevention and other treatment is relatively low; Items' applicable percentage of applicability evaluation are more than 91% except the item of guide simplicity. Comprehensive applicability evaluation, The percentage of the guideline applicable to clinical practice accounted for 94.94%. The consistency rate of syndrome differentiation and clinical application is more than 96% in addition to prescription medication, other treatments and health preserving and prevention of the guidelines apply consistency of application evaluation. The percentage of good treatment effect accounted for 92.96% of application effect evaluation. The safety percentage is 99.89% and economy is 97.45%. The research shows that of Guidelines for the Diagnosis and Treatment of Common Diseases of Pediatrics in Traditional Chinese Medicine quality level is good and is basically applicable to pediatric clinical practice which can be used as a standardized recommendation of pediatric common diseases' treatment specification. A small part of the guidelines are not applicable and need to be further consummated. Health preserving and prevention and other treatment of the guideline need to be revised. Copyright© by the Chinese Pharmaceutical Association.

An investigation into the bacterial contamination of goniolenses in use in clinical practice.

PubMed

Grundon, Rachael; Scurrell, Emma; Mould, John; Hayton-Lee, Emma; Heinrich, Christine

2017-12-18

Objectives To report the incidence and evaluate the clinical significance of goniolens bacterial contamination in clinical use in dogs with three different usage protocols and one with an added cleaning protocol. Animals Studied and Methods Three groups of twenty dogs undergoing gonioscopy at a private practice in the UK had the goniolenses swabbed for bacteriology culture and identification prior to placement on the cornea. Three protocols of lens use, with 2 different types of goniolens, were studied. One protocol was then repeated with 21 dogs with a lens cleaning protocol prior to storage. Results Low levels of bacterial contamination were found in all 3 initial groups (10-15%). No correlation was found between usage protocol used and rate of contamination and no correlation was found between length of storage between use and contamination. All bacteria cultured were considered naturally occurring commensals for the canine eye and environment. The group with a cleaning protocol had a 4.7% contamination rate. This was not statistically different from the non-cleaning groups. Conclusions The rate of bacterial contamination of goniolenses in clinical practice is low and the bacterial contaminants consist of commensal bacteria, unlikely to be of detriment to the eye. Minimal contamination of the goniolenses was found and this did not appear to be of clinical significance. The introduction of a simple cleaning protocol did not produce a statistically significant reduction in bacterial contamination. © 2017 American College of Veterinary Ophthalmologists.

Organizational structure for addressing the attributes of the ideal healthcare delivery system.

PubMed

Cowen, Mark; Halasyamani, Lakshmi K; McMurtrie, Daniel; Hoffman, Denise; Polley, Theodore; Alexander, Jeffrey A

2008-01-01

The Institute of Medicine's (IOM) report Crossing the Quality Chasm described the aims, characteristics, and components of the ideal healthcare system but did not provide the templates of organizational structures needed to achieve this vision. In this article, we review three principles of effective organizations to inform the design of a facilitative clinical care structure: a focus on the patient and caregiving team, the use of information, and connectivity with executive and operational leadership. These concepts can be realized in an organizational chart that is inverted to place patients and their care providers on top, flat with few degrees of separation between patients and executive leadership, and webbed to reflect connections to the professional and ancillary departments. An example of a recently implemented clinical care infrastructure follows this discussion. This model divides the patient population into nonexclusive subgroups, each with an interdisciplinary collaborative practice team that oversees and advocates the subgroup's clinical care activities. The organization's interdisciplinary practice council, in conjunction with its physician and nursing practice councils, backs these teams, providing a second layer of support. The council layer is connected to the health system board through the clinical oversight group, whose core membership consists of council chairs, the chief executive officer, and the chief medical and nursing officers. Clinical information for planning and evaluation is available at all levels. This model provides a framework for identifying the individuals and processes necessary to achieve IOM's vision.

Molecular markers for urothelial bladder cancer prognosis: toward implementation in clinical practice.

PubMed

van Rhijn, Bas W G; Catto, James W; Goebell, Peter J; Knüchel, Ruth; Shariat, Shahrokh F; van der Poel, Henk G; Sanchez-Carbayo, Marta; Thalmann, George N; Schmitz-Dräger, Bernd J; Kiemeney, Lambertus A

2014-10-01

To summarize the current status of clinicopathological and molecular markers for the prediction of recurrence or progression or both in non-muscle-invasive and survival in muscle-invasive urothelial bladder cancer, to address the reproducibility of pathology and molecular markers, and to provide directions toward implementation of molecular markers in future clinical decision making. Immunohistochemistry, gene signatures, and FGFR3-based molecular grading were used as molecular examples focussing on prognostics and issues related to robustness of pathological and molecular assays. The role of molecular markers to predict recurrence is limited, as clinical variables are currently more important. The prediction of progression and survival using molecular markers holds considerable promise. Despite a plethora of prognostic (clinical and molecular) marker studies, reproducibility of pathology and molecular assays has been understudied, and lack of reproducibility is probably the main reason that individual prediction of disease outcome is currently not reliable. Molecular markers are promising to predict progression and survival, but not recurrence. However, none of these are used in the daily clinical routine because of reproducibility issues. Future studies should focus on reproducibility of marker assessment and consistency of study results by incorporating scoring systems to reduce heterogeneity of reporting. This may ultimately lead to incorporation of molecular markers in clinical practice. Copyright © 2014 Elsevier Inc. All rights reserved.

Ultra-high definition (8K UHD) endoscope: our first clinical success.

PubMed

Yamashita, Hiromasa; Aoki, Hisae; Tanioka, Kenkichi; Mori, Toshiyuki; Chiba, Toshio

2016-01-01

We have started clinical application of 8K ultra-high definition (UHD; 7680 × 4320 pixels) imaging technology, which is a 16-fold higher resolution than the current 2K high-definition (HD; 1920 × 1080 pixels) technology, to an endoscope for advanced laparoscopic surgery. Based on preliminary testing experience and with subsequent technical and system improvements, we then proceeded to perform two cases of cholecystectomy and were able to achieve clinical success with an 8K UHD endoscopic system, which consisted of an 8K camera, a 30-degrees angled rigid endoscope with a lens adapter, a pair of 300-W xenon light sources, an 85-inch 8K LCD and an 8K video recorder. These experimental and clinical studies revealed the engineering and clinical feasibility of the 8K UHD endoscope, enabling us to have a positive outlook on its prospective use in clinical practice. The 8K UHD endoscopy promises to open up new possibilities for intricate procedures including anastomoses of thin nerves and blood vessels as well as more confident surgical resections of a diversity of cancer tissues. 8K endoscopic imaging, compared to imaging by the current 2K imaging technology, is very likely to lead to major changes in the future of medical practice.

Use of anti-mullerian hormone for testing ovarian reserve: a survey of 796 infertility clinics worldwide.

PubMed

Tobler, Kyle J; Shoham, Gon; Christianson, Mindy S; Zhao, Yulian; Leong, Milton; Shoham, Zeev

2015-10-01

The aim of this study is to assess how anti-mullerian hormone (AMH) is used worldwide to test ovarian reserve and guide in vitro fertilization (IVF) cycle management. An internet-based survey was sent electronically to registered IVF providers within the IVF-Worldwide.com network. This survey consisted of nine questions which assessed the clinics' use of AMH. The questionnaire was completed online through the IVF-Worldwide.com website, and quality assurance tools were used to verify that only one survey was completed per clinical IVF center. Results are reported as the proportion of IVF cycles represented by a particular answer choice. Survey responses were completed from 796 globally distributed IVF clinics, representing 593,200 IVF cycles worldwide. Sixty percent of the respondent-IVF cycles reported to use AMH as a first line test, and 54 % reported it as the best test for evaluating ovarian reserve. Eighty-nine percent reported that AMH results were extremely relevant or relevant to clinical practice. However in contrast, for predicting live birth rate, 81 % reported age as the best predictor. AMH is currently considered a first line test for evaluating ovarian reserve and is considered relevant to clinical practice by the majority of IVF providers.

Orientation based on nursing diagnoses. Old concepts in today's practice.

PubMed

Anderson, L K; Vincent, N

1991-10-01

Although many operating room orientation programs contain content necessary to meet accrediting guidelines, very few tie the nursing process to the content. Our orientation is structured within a nursing framework (ie, Dr Gordon's "Eleven Functional Health Patterns") and emphasizes nursing diagnoses, theory, and clinical competencies. Although the new orientation program has been in effect for only two years, we feel the following list reflects the positive outcomes so far: decreased staff turnover (ie, one nurse out of 26 full-time equivalents in 18 months), increased success in recruiting nurses into the operating room (ie, multiple applicants as positions open), new nurses demonstrate comfort with basic perioperative nursing practice with-in six months, and nurses who did not complete new orientation program are requesting all or portions of the content. By using this plan, essential aspects of perioperative practice are consistent with hospital-wide nursing practice, practice standards for the operating room, and accrediting standards.

Patients, practices, and relationships: challenges and lessons learned from the Kentucky Ambulatory Network (KAN) CaRESS clinical trial.

PubMed

Love, Margaret M; Pearce, Kevin A; Williamson, M Ann; Barron, Mary A; Shelton, Brent J

2006-01-01

The Cardiovascular Risk Education and Social Support (CaRESS) study is a randomized controlled trial that evaluates a social support intervention toward reducing cardiovascular risk in type 2 diabetic patients. It involves multiple community-based practice sites from the Kentucky Ambulatory Network (KAN), which is a regional primary care practice-based research network (PBRN). CaRESS also implements multiple modes of data collection. The purpose of this methods article is to share lessons learned that might be useful to others developing or implementing complex studies that consent patients in PBRNs. Key points include building long-term relationships with the clinicians, adaptability when integrating into practice sites, adequate funding to support consistent data management and statistical support during all phases of the study, and creativity and perseverance for recruiting patients and practices while maintaining the integrity of the protocol.

The feasibility of using UML to compare the impact of different brands of computer system on the clinical consultation.

PubMed

Kumarapeli, Pushpa; de Lusignan, Simon; Koczan, Phil; Jones, Beryl; Sheeler, Ian

2007-01-01

UK general practice is universally computerised, with computers used in the consulting room at the point of care. Practices use a range of different brands of computer system, which have developed organically to meet the needs of general practitioners and health service managers. Unified Modelling Language (UML) is a standard modelling and specification notation widely used in software engineering. To examine the feasibility of UML notation to compare the impact of different brands of general practice computer system on the clinical consultation. Multi-channel video recordings of simulated consultation sessions were recorded on three different clinical computer systems in common use (EMIS, iSOFT Synergy and IPS Vision). User action recorder software recorded time logs of keyboard and mouse use, and pattern recognition software captured non-verbal communication. The outputs of these were used to create UML class and sequence diagrams for each consultation. We compared 'definition of the presenting problem' and 'prescribing', as these tasks were present in all the consultations analysed. Class diagrams identified the entities involved in the clinical consultation. Sequence diagrams identified common elements of the consultation (such as prescribing) and enabled comparisons to be made between the different brands of computer system. The clinician and computer system interaction varied greatly between the different brands. UML sequence diagrams are useful in identifying common tasks in the clinical consultation, and for contrasting the impact of the different brands of computer system on the clinical consultation. Further research is needed to see if patterns demonstrated in this pilot study are consistently displayed.

A consensus for the development of a vector model to assess clinical complexity.

PubMed

Corazza, Gino Roberto; Klersy, Catherine; Formagnana, Pietro; Lenti, Marco Vincenzo; Padula, Donatella

2017-12-01

The progressive rise in multimorbidity has made management of complex patients one of the most topical and challenging issues in medicine, both in clinical practice and for healthcare organizations. To make this easier, a score of clinical complexity (CC) would be useful. A vector model to evaluate biological and extra-biological (socio-economic, cultural, behavioural, environmental) domains of CC was proposed a few years ago. However, given that the variables that grade each domain had never been defined, this model has never been used in clinical practice. To overcome these limits, a consensus meeting was organised to grade each domain of CC, and to establish the hierarchy of the domains. A one-day consensus meeting consisting of a multi-professional panel of 25 people was held at our Hospital. In a preliminary phase, the proponents selected seven variables as qualifiers for each of the five above-mentioned domains. In the course of the meeting, the panel voted for five variables considered to be the most representative for each domain. Consensus was established with 2/3 agreement, and all variables were dichotomised. Finally, the various domains were parametrized and ranked within a feasible vector model. A Clinical Complexity Index was set up using the chosen variables. All the domains were graphically represented through a vector model: the biological domain was chosen as the most significant (highest slope), followed by the behavioural and socio-economic domains (intermediate slope), and lastly by the cultural and environmental ones (lowest slope). A feasible and comprehensive tool to evaluate CC in clinical practice is proposed herein.

The mediating effect of context variation in mixed practice for transfer of basic science.

PubMed

Kulasegaram, Kulamakan; Min, Cynthia; Howey, Elizabeth; Neville, Alan; Woods, Nicole; Dore, Kelly; Norman, Geoffrey

2015-10-01

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. Practicing multiple concepts together (mixed practice mode) has been shown superior to practicing concepts separately (blocked practice mode) for transfer. This study examined the effect of single and multiple practice contexts for both mixed and blocked practice modalities on transfer performance. We looked at performance on near transfer (familiar contexts) cases and far transfer (unfamiliar contexts) cases. First year psychology students (n = 42) learned three physiological concepts in a 2 × 2 factorial study (one or two practice contexts and blocked or mixed practice). Each concept was practiced with two clinical cases; practice context was defined as the number of organ systems used (one system per concept vs. two systems). In blocked practice, two practice cases followed each concept; in mixed practice, students learned all concepts before seeing six practice cases. Transfer testing consisted of correctly classifying and explaining 15 clinical cases involving near and far transfer. The outcome was ratings of quality of explanations on a 0-3 scale. The repeated measures analysis showed a significant near versus far by organ system interaction [F(1,38) = 3.4, p < 0.002] with practice with a single context showing lower far transfer scores than near transfer [0.58 (0.37)-0.83 (0.37)] compared to the two contexts which had similar far and near transfer scores [1.19 (0.50)-1.01 (0.38)]. Practicing with two organ contexts had a significant benefit for far transfer regardless of mixed or blocked practice; the single context mixed practice group had the lowest far transfer performance; this was a large effect size (Cohen's d = 0.81). Using only one practice context during practice significantly lowers performance even with the usually superior mixed practice mode. Novices should be exposed to multiple contexts and mixed practice to facilitate transfer.

Human Milk Handling and Storage Practices Among Peer Milk-Sharing Mothers.

PubMed

Reyes-Foster, Beatriz M; Carter, Shannon K; Hinojosa, Melanie Sberna

2017-02-01

Peer milk sharing, the noncommercial sharing of human milk from one parent or caretaker directly to another for the purposes of feeding a child, appears to be an increasing infant-feeding practice. Although the U.S. Food and Drug Administration has issued a warning against the practice, little is known about how people who share human milk handle and store milk and whether these practices are consistent with clinical safety protocols. Research aim: This study aimed to learn about the milk-handling practices of expressed human milk by milk-sharing donors and recipient caretakers. In this article, we explore the degree to which donors and recipients adhere to the Academy of Breastfeeding Medicine clinical recommendations for safe handling and storage. Online surveys were collected from 321 parents engaged in peer milk sharing. Univariate descriptive statistics were used to describe the safe handling and storage procedures for milk donors and recipients. A two-sample t-test was used to compare safety items common to each group. Multivariate ordinary least squares regression analysis was used to examine sociodemographic correlates of milk safety practices within the sample group. Findings indicate that respondents engaged in peer milk sharing report predominantly positive safety practices. Multivariate analysis did not reveal any relationship between safety practices and sociodemographic characteristics. The number of safe practices did not differ between donors and recipients. Parents and caretakers who participate in peer human milk sharing report engaging in practices that should reduce risk of bacterial contamination of expressed peer shared milk. More research on this particular population is recommended.

Prevention and treatment of chemotherapy-induced neutropenia with the biosimilar filgrastim: a non-interventional observational study of clinical practice patterns.

PubMed

Tesch, Hans; Ulshöfer, Thomas; Vehling-Kaiser, Ursula; Ottillinger, Bertram; Bulenda, Dietmar; Turner, Matthew

2015-01-01

Biosimilars are similar but non-identical versions of existing biological drugs. The HEXAFIL study was an observational study that assessed the clinical usage, safety and efficacy of the biosimilar filgrastim in routine clinical practice in Germany. A total of 1,337 cancer patients received the biosimilar filgrastim for primary prophylaxis (PP), secondary prophylaxis (SP) or interventional treatment (TX) plus chemotherapy. Data including neutropenic complications and adverse events (AEs) were documented for up to 3 consecutive cycles. In cycle 1, 44.9% of the patients received the biosimilar filgrastim as PP, 31.0% as SP, and 23.6% as TX. Approximately 90% of the patients required no modifications to their chemotherapy regimen, with lower rates among the PP/SP versus the TX patients. Neutropenic complications occurred in 7.9%, 6.9%, and 3.9% of the patients (cycles 1, 2, and 3, respectively). Only 1.8% of the patients experienced febrile neutropenia during cycle 1. Earlier and longer filgrastim treatment reduced grade 3/4 leukopenia and neutropenic complications. The observed safety/tolerability profile was as expected; the most common AE (4.3%) was musculoskeletal back/bone pain. In this observational real-life study of clinical practice, the biosimilar filgrastim was effective and well tolerated, with results consistent with those reported in phase II and phase III trials. © 2015 S. Karger GmbH, Freiburg.

Staff perceptions of using outcome measures in stroke rehabilitation.

PubMed

Burton, Louisa-Jane; Tyson, Sarah; McGovern, Alison

2013-05-01

The use of standardised outcome measures is an integral part of stroke rehabilitation and is widely recommended as good practice. However, little is known about how measures are actually used or their impact. This study aimed to identify current clinical practice; how healthcare professionals working in stroke rehabilitation use outcome measures and their perceptions of the benefits and barriers to use. Eighty-four Health Care Professionals and 12 service managers and commissioners working in stroke services across a large UK county were surveyed by postal questionnaire. Ninety-six percent of clinical respondents used at least one measure, however, less than half used measures regularly during a patient's stay. The mean number of tools used was 3.2 (SD = 1.9). Eighty-one different tools were identified; 16 of which were unpublished and unvalidated. Perceived barriers in using outcome measures in day-to-day clinical practice included lack of resources (time and training) and lack of knowledge of appropriate measures. Benefits identified were to demonstrate the effectiveness of rehabilitation interventions and monitor patients' progress. Although the use of outcome measures is prevalent in clinical practice, there is little consistency in the tools utilised. The term "outcome measures" is used, but staff rarely used the measures at appropriate time points to formally assess and evaluate outcome. The term "measurement tool" more accurately reflects the purposes to which they were put and potential benefits. Further research to overcome the barriers in using standardised measurement tools and evaluate the impact of implementation on clinical practice is needed. • Health professionals working in stroke rehabilitation should work together to agree when and how outcome measures can be most effectively used in their service. • Efforts should be made to ensure that standardised tools are used to measure outcome at set time-points during rehabilitation, in order to achieve the anticipated benefits. • Communication between service providers and commissioners could be improved to highlight the barriers in using standardised measures of outcome.

Survey of integrative lumbar spinal stenosis treatment in Korean medicine doctors: preliminary data for clinical practice guidelines.

PubMed

Lee, Yoon Jae; Shin, Joon-Shik; Lee, Jinho; Kim, Me-Riong; Ahn, Yong-Jun; Shin, Ye-Sle; Park, Ki Byung; Shin, Byung-Cheul; Lee, Myeong Soo; Kim, Joo-Hee; Cho, Jae-Heung; Ha, In-Hyuk

2017-08-29

Considering that large variations exist amongst practitioners in lumbar disorder management and the significant costs that lumbar disorders incur, determining clinical practice patterns to provide preliminary data for standardization should be given higher priority. Lumbar spinal stenosis (LSS) is commonly treated using integrative non-surgical methods by Korean medicine doctors (KMDs) in Korea, and this is the first study to assess current Korean medicine practice trends for LSS. A survey on KMD diagnosis, treatment, prognosis and decision-making in LSS treatment was developed in a 3-step procedure of preliminary drafting, revision based on extramural expert opinion, and final editing. The survey was conducted at the internal conference of a spine-specialty Korean medicine hospital on January 25th, 2015. The response rate was high at 79.19% (n = 118/149). Participants replied that they treated 7.3 ± 6.8 LSS patients/day using a multimodal treatment method consisting of acupuncture, pharmacopuncture, herbal medicine, Chuna manipulation, and electroacupuncture. Acupuncture mainly used Ashi points and MSAT, and pharmacopuncture mainly Shinbaro solution. The most frequently prescribed herbal medicine was Chungpa-jun, and the most commonly applied Chuna techniques were sidelying lumbar extension dysfunction correction technique, and prone lumbosacral joint distraction method. Radiological findings were mainly referred to for diagnosis, and clinical symptoms, age, radiological findings, and medical history were regarded to be important for prognosis. Participants replied that 7.8 ± 3.3 weeks were required for 50% reduction in pain, and 16.1 ± 7.7 weeks for 80% reduction. These results suggest that KMDs in Korea combine a conventional approach to LSS and a Korean medicine approach to low back pain for integration of empirical- and evidence-based diagnosis and treatment. The findings may contribute in bridging the divide between evidence and clinical practice guidelines for Korean medicine treatment of LSS and real-world clinical practice in future research.

Automated quality checks on repeat prescribing.

PubMed Central

Rogers, Jeremy E; Wroe, Christopher J; Roberts, Angus; Swallow, Angela; Stables, David; Cantrill, Judith A; Rector, Alan L

2003-01-01

BACKGROUND: Good clinical practice in primary care includes periodic review of repeat prescriptions. Markers of prescriptions that may need review have been described, but manually checking all repeat prescriptions against the markers would be impractical. AIM: To investigate the feasibility of computerising the application of repeat prescribing quality checks to electronic patient records in United Kingdom (UK) primary care. DESIGN OF STUDY: Software performance test against benchmark manual analysis of cross-sectional convenience sample of prescribing documentation. SETTING: Three general practices in Greater Manchester, in the north west of England, during a 4-month period in 2001. METHOD: A machine-readable drug information resource, based on the British National Formulary (BNF) as the 'gold standard' for valid drug indications, was installed in three practices. Software raised alerts for each repeat prescribed item where the electronic patient record contained no valid indication for the medication. Alerts raised by the software in two practices were analysed manually. Clinical reaction to the software was assessed by semi-structured interviews in three practices. RESULTS: There was no valid indication in the electronic medical records for 14.8% of repeat prescribed items. Sixty-two per cent of all alerts generated were incorrect. Forty-three per cent of all incorrect alerts were as a result of errors in the drug information resource, 44% to locally idiosyncratic clinical coding, 8% to the use of the BNF without adaptation as a gold standard, and 5% to the inability of the system to infer diagnoses that, although unrecorded, would be 'obvious' to a clinical reading the record. The interviewed clinicians supported the goals of the software. CONCLUSION: Using electronic records for secondary decision support purposes will benefit from (and may require) both more consistent electronic clinical data collection across multiple sites, and reconciling clinicians' willingness to infer unstated but 'obvious' diagnoses with the machine's inability to do the same. PMID:14702902

48 CFR 30.201-4 - Contract clauses.

Code of Federal Regulations, 2010 CFR

2010-10-01

... established cost accounting practices consistently. (b) Disclosure and consistency of cost accounting practices. (1) Insert the clause at FAR 52.230-3, Disclosure and Consistency of Cost Accounting Practices... follow consistently its established cost accounting practices. (c) Disclosure and Consistency of Cost...

Exploring extended scope of practice in dietetics: A systems approach.

PubMed

Ryan, Dominique; Pelly, Fiona; Purcell, Elizabeth

2017-09-01

The aim of this study was to explore health professionals' perceptions of an extended scope of a practice clinic, and develop a framework using a systems approach to facilitate extended scope models across various health settings. A qualitative investigation using semi-structured interviews with four health professionals involved in an extended scope dietitian-led gastroenterology clinic in a hospital in regional Queensland was conducted. A case study design was utilised to investigate interviewees' perceptions of the clinic. Participants were conveniently, purposively sampled. Transcript analysis involved a descriptive analytical approach. Interviewee responses were coded and categorised into themes, and investigator triangulation was used to ensure consistency between individual analyses. A secondary interpretative analysis was conducted where relationships between key themes were mapped to the Systems Engineering Initiative for Patient Safety work system model. Interviewees identified various factors as vital inputs to the work system. These were categorised into the four key elements: stakeholder support, resources, planning and the dietitian. Clinic outcomes were categorised into the impact on four key groups: patients, the dietitian, the multidisciplinary team and the health system. Mapping of the relationships between inputs and outcomes resulted in an implementation framework for extended scope of practice. Extended scope of practice in dietetics may provide positive outcomes for various stakeholders. However, further development of extended scope roles for dietitians requires increased advocacy and support from governments, professional bodies, training institutions and dietitians. We have developed an implementation framework which can be utilised by health professionals interested in embracing an extended scope model of care. © 2016 Dietitians Association of Australia.

Measuring clinical management by physicians and nurses in European hospitals: development and validation of two scales.

PubMed

Plochg, Thomas; Arah, Onyebuchi A; Botje, Daan; Thompson, Caroline A; Klazinga, Niek S; Wagner, Cordula; Mannion, Russell; Lombarts, Kiki

2014-04-01

Clinical management is hypothesized to be critical for hospital management and hospital performance. The aims of this study were to develop and validate professional involvement scales for measuring the level of clinical management by physicians and nurses in European hospitals. Testing of validity and reliability of scales derived from a questionnaire of 21 items was developed on the basis of a previous study and expert opinion and administered in a cross-sectional seven-country research project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE). A sample of 3386 leading physicians and nurses working in 188 hospitals located in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. Validity and reliability of professional involvement scales and subscales. Psychometric analysis yielded four subscales for leading physicians: (i) Administration and budgeting, (ii) Managing medical practice, (iii) Strategic management and (iv) Managing nursing practice. Only the first three factors applied well to the nurses. Cronbach's alpha for internal consistency ranged from 0.74 to 0.86 for the physicians, and from 0.61 to 0.81 for the nurses. Except for the 0.74 correlation between 'Administration and budgeting' and 'Managing medical practice' among physicians, all inter-scale correlations were <0.70 (range 0.43-0.61). Under testing for construct validity, the subscales were positively correlated with 'formal management roles' of physicians and nurses. The professional involvement scales appear to yield reliable and valid data in European hospital settings, but the scale 'Managing medical practice' for nurses needs further exploration. The measurement instrument can be used for international research on clinical management.

"Bed Side" Human Milk Analysis in the Neonatal Intensive Care Unit: A Systematic Review.

PubMed

Fusch, Gerhard; Kwan, Celia; Kotrri, Gynter; Fusch, Christoph

2017-03-01

Human milk analyzers can measure macronutrient content in native breast milk to tailor adequate supplementation with fortifiers. This article reviews all studies using milk analyzers, including (i) evaluation of devices, (ii) the impact of different conditions on the macronutrient analysis of human milk, and (iii) clinical trials to improve growth. Results lack consistency, potentially due to systematic errors in the validation of the device, or pre-analytical sample preparation errors like homogenization. It is crucial to introduce good laboratory and clinical practice when using these devices; otherwise a non-validated clinical usage can severely affect growth outcomes of infants. Copyright © 2016 Elsevier Inc. All rights reserved.

A Slovenian version of the "clinical learning environment, supervision and nurse teacher scale (Cles+T)" and its comparison with the Croatian version.

PubMed

Žvanut, Boštjan; Lovrić, Robert; Kolnik, Tamara Štemberger; Šavle, Majda; Pucer, Patrik

2018-05-01

Nursing clinical learning environments are particularly important for the achievement of good practice in clinical training of student nurses, and thus, for the nursing competence development. Hence, it is important to have an instrument consisting of reliable and valid criteria for assessing the clinical learning environment, applicable in different contexts, and translated in the respondents mother tongue. The goal of the present research was to test the reliability and validity of the Slovenian version of the "Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale", and to compare it with the Croatian version. The data was collected between 10 March and 10 June 2015 at four Slovenian institutions, where nursing BSc study programmes are performed. The final sample consisted of 232 students (response rate 68.8%): 81.9% were females and 18.1% males, average age was 23. The translated instrument in Slovenian language resulted as reliable and valid, it reflects the expected five factors of the original version despite some minor problems in the factor structure and in test-retest. The most important difference between the Slovenian and Croatian version is in the factor structure regarding the implementation of roles in clinical learning environment. Copyright © 2018 Elsevier Ltd. All rights reserved.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline.

PubMed

Button, Brenda M; Wilson, Christine; Dentice, Ruth; Cox, Narelle S; Middleton, Anna; Tannenbaum, Esta; Bishop, Jennifer; Cobb, Robyn; Burton, Kate; Wood, Michelle; Moran, Fiona; Black, Ryan; Bowen, Summar; Day, Rosemary; Depiazzi, Julie; Doiron, Katherine; Doumit, Michael; Dwyer, Tiffany; Elliot, Alison; Fuller, Louise; Hall, Kathleen; Hutchins, Matthew; Kerr, Melinda; Lee, Annemarie L; Mans, Christina; O'Connor, Lauren; Steward, Ranjana; Potter, Angela; Rasekaba, Tshepo; Scoones, Rebecca; Tarrant, Ben; Ward, Nathan; West, Samantha; White, Dianne; Wilson, Lisa; Wood, Jamie; Holland, Anne E

2016-05-01

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand. © 2016 The Authors Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.

Dysphagia management in a 3-year dental hygiene education programme in Japan.

PubMed

Sato, Yoko; Miura, Ai; Saito, Atsushi

2005-11-01

This paper reports the development and evaluation of a dysphagia management course taught to the third year dental hygiene students during 2004-2005 as one framework of the new curriculum. The course consisted of lectures by specialists in each field, basic practice and clinical practice at a facility for the elderly. Evaluation of the course showed that improvements were found in students' understanding in certain subjects when compared with that during 2003-2004. Scores on the post-test were statistically significantly higher than those on the pre-test, showing that basic knowledge of the students had been improved. Introductory and follow-up lectures by dental hygiene instructors and appropriate basic practice enhanced the learning process of the students. In the clinical practice, the concept of 'dental hygiene process of care' was incorporated. The dental hygiene process facilitated the students in planning and implementing dental hygiene care that meets the needs of the individual clients. This active learning experience enhanced the students' understanding of dysphagia management. Although further improvements are necessary, this dysphagia management course should help dental hygienists in playing a greater role in the field of oral care and dysphagia rehabilitation.

PROPOSAL FOR A SIMPLE AND EFFICIENT MONTHLY QUALITY MANAGEMENT PROGRAM ASSESSING THE CONSISTENCY OF ROBOTIC IMAGE-GUIDED SMALL ANIMAL RADIATION SYSTEMS

PubMed Central

Brodin, N. Patrik; Guha, Chandan; Tomé, Wolfgang A.

2015-01-01

Modern pre-clinical radiation therapy (RT) research requires high precision and accurate dosimetry to facilitate the translation of research findings into clinical practice. Several systems are available that provide precise delivery and on-board imaging capabilities, highlighting the need for a quality management program (QMP) to ensure consistent and accurate radiation dose delivery. An ongoing, simple, and efficient QMP for image-guided robotic small animal irradiators used in pre-clinical RT research is described. Protocols were developed and implemented to assess the dose output constancy (based on the AAPM TG-61 protocol), cone-beam computed tomography (CBCT) image quality and object representation accuracy (using a custom-designed imaging phantom), CBCT-guided target localization accuracy and consistency of the CBCT-based dose calculation. To facilitate an efficient read-out and limit the user dependence of the QMP data analysis, a semi-automatic image analysis and data representation program was developed using the technical computing software MATLAB. The results of the first six months experience using the suggested QMP for a Small Animal Radiation Research Platform (SARRP) are presented, with data collected on a bi-monthly basis. The dosimetric output constancy was established to be within ±1 %, the consistency of the image resolution was within ±0.2 mm, the accuracy of CBCT-guided target localization was within ±0.5 mm, and dose calculation consistency was within ±2 s (± 3 %) per treatment beam. Based on these results, this simple quality assurance program allows for the detection of inconsistencies in dosimetric or imaging parameters that are beyond the acceptable variability for a reliable and accurate pre-clinical RT system, on a monthly or bi-monthly basis. PMID:26425981

Proposal for a Simple and Efficient Monthly Quality Management Program Assessing the Consistency of Robotic Image-Guided Small Animal Radiation Systems.

PubMed

Brodin, N Patrik; Guha, Chandan; Tomé, Wolfgang A

2015-11-01

Modern pre-clinical radiation therapy (RT) research requires high precision and accurate dosimetry to facilitate the translation of research findings into clinical practice. Several systems are available that provide precise delivery and on-board imaging capabilities, highlighting the need for a quality management program (QMP) to ensure consistent and accurate radiation dose delivery. An ongoing, simple, and efficient QMP for image-guided robotic small animal irradiators used in pre-clinical RT research is described. Protocols were developed and implemented to assess the dose output constancy (based on the AAPM TG-61 protocol), cone-beam computed tomography (CBCT) image quality and object representation accuracy (using a custom-designed imaging phantom), CBCT-guided target localization accuracy and consistency of the CBCT-based dose calculation. To facilitate an efficient read-out and limit the user dependence of the QMP data analysis, a semi-automatic image analysis and data representation program was developed using the technical computing software MATLAB. The results of the first 6-mo experience using the suggested QMP for a Small Animal Radiation Research Platform (SARRP) are presented, with data collected on a bi-monthly basis. The dosimetric output constancy was established to be within ±1 %, the consistency of the image resolution was within ±0.2 mm, the accuracy of CBCT-guided target localization was within ±0.5 mm, and dose calculation consistency was within ±2 s (±3%) per treatment beam. Based on these results, this simple quality assurance program allows for the detection of inconsistencies in dosimetric or imaging parameters that are beyond the acceptable variability for a reliable and accurate pre-clinical RT system, on a monthly or bi-monthly basis.

Diagnostic consistency and interchangeability of schizophrenic disorders and bipolar disorders: A 7-year follow-up study.

PubMed

Hung, Yen-Ni; Yang, Shu-Yu; Kuo, Chian-Jue; Lin, Shih-Ku

2018-03-01

The change in psychiatric diagnoses in clinical practice is not an unusual phenomenon. The interchange between the diagnoses of schizophrenic disorders and bipolar disorders is a major clinical issue because of the differences in treatment regimens and long-term prognoses. In this study, we used a nationwide population-based sample to compare the diagnostic consistency and interchange rate between schizophrenic disorders and bipolar disorders. In total, 25 711 and 11 261 patients newly diagnosed as having schizophrenic disorder and bipolar disorder, respectively, were retrospectively enrolled from the Psychiatric Inpatient Medical Claims database between 2001 and 2005. We followed these two cohorts for 7 years to determine whether their diagnoses were consistent throughout subsequent hospitalizations. The interchange between the two diagnoses was analyzed. In the schizophrenic disorder cohort, the overall diagnostic consistency rate was 87.3% and the rate of change to bipolar disorder was 3.0% during the 7-year follow-up. Additional analyses of subtypes revealed that the change rate from schizoaffective disorder to bipolar disorder was 12.0%. In the bipolar disorder cohort, the overall diagnostic consistency rate was 71.9% and the rate of change to schizophrenic disorder was 8.3%. Changes in the diagnosis of a major psychosis are not uncommon. The interchange between the diagnoses of schizophrenic disorders and bipolar disorders might be attributed to the evolution of clinical symptoms and the observation of preserved social functions that contradict the original diagnosis. While making a psychotic diagnosis, clinicians should be aware of the possibility of the change in diagnosis in the future. © 2017 The Authors. Psychiatry and Clinical Neurosciences © 2017 Japanese Society of Psychiatry and Neurology.

Theory and interpretation in qualitative studies from general practice: Why and how?

PubMed

Malterud, Kirsti

2016-03-01

In this article, I want to promote theoretical awareness and commitment among qualitative researchers in general practice and suggest adequate and feasible theoretical approaches. I discuss different theoretical aspects of qualitative research and present the basic foundations of the interpretative paradigm. Associations between paradigms, philosophies, methodologies and methods are examined and different strategies for theoretical commitment presented. Finally, I discuss the impact of theory for interpretation and the development of general practice knowledge. A scientific theory is a consistent and soundly based set of assumptions about a specific aspect of the world, predicting or explaining a phenomenon. Qualitative research is situated in an interpretative paradigm where notions about particular human experiences in context are recognized from different subject positions. Basic theoretical features from the philosophy of science explain why and how this is different from positivism. Reflexivity, including theoretical awareness and consistency, demonstrates interpretative assumptions, accounting for situated knowledge. Different types of theoretical commitment in qualitative analysis are presented, emphasizing substantive theories to sharpen the interpretative focus. Such approaches are clearly within reach for a general practice researcher contributing to clinical practice by doing more than summarizing what the participants talked about, without trying to become a philosopher. Qualitative studies from general practice deserve stronger theoretical awareness and commitment than what is currently established. Persistent attention to and respect for the distinctive domain of knowledge and practice where the research deliveries are targeted is necessary to choose adequate theoretical endeavours. © 2015 the Nordic Societies of Public Health.

Interventions to support and develop clinician-researcher leadership in one health district.

PubMed

Fry, Margaret; Dombkins, Anthony

2017-07-10

Purpose Clinical leadership, researcher capacity and a culture of clinical inquiry are needed in the clinical workforce. The purpose of this paper is to report on a program which was used to develop and support clinicians to explore practice, implement innovation, translate evidence and build researcher capacity. Design/methodology/approach This pragmatic paper presents a case study of a nursing and midwifery clinician-researcher development program. The multi-site, multi-modal program focused on education, mentoring and support, communication networks, and clinician-university partnerships strategies to build workforce capacity and leadership. Findings Over 2,000 staff have been involved in the program representing a range of health disciplines. The study day program has been delivered to 500 participants with master classes having over 1,500 attendees. The research mentor program has demonstrated that participants increased their confidence for research leadership roles and are pursuing research and quality assurance projects. Communication strategies improved the visibility of nursing and midwifery. Research limitations/implications This case study was conducted in one health district, which may not have relevance to other geographical areas. The small numbers involved in the research mentor program need to be considered when reviewing the findings. Practical implications The program has been a catalyst for developing a research culture, clinical leadership and research networks that strengthen workforce capacity. Building researcher skills in the workforce will better support quality healthcare and the examination of everyday practice. Social implications Building a culture of healthcare that is based on inquiry and evidence-based practice will lead to more appropriate and consistent healthcare delivery. Consumers have the right to expect health clinicians will challenge everyday practice and have the skills and capability to translate or generate best evidence to underpin professional and service delivery. Originality/value This paper provides strategies for building workforce researcher capacity and capability. The program provides opportunity for building research networks and role modeling the value and importance of research to practice and quality improvement.

The importance of academic literacy for undergraduate nursing students and its relationship to future professional clinical practice: A systematic review.

PubMed

Jefferies, Diana; McNally, Stephen; Roberts, Katriona; Wallace, Anna; Stunden, Annette; D'Souza, Suzanne; Glew, Paul

2018-01-01

This systematic review was designed to assess the importance of academic literacy for undergraduate nursing students and its relationship to future professional clinical practice. It aimed to explore the link between academic literacy and writing in an undergraduate nursing degree and the development of critical thinking skills for their future professional clinical practice. A systematic review of qualitative studies and expert opinion publications. A systematic literature search was undertaken of the following databases: ERIC, PubMed, CINAHL, MEDLINE and Scopus. All papers reviewed were from 2000 to 2016 and were written in English. We identified 981 studies and expert opinion papers from the selected databases. After reviewing key words and abstracts for the inclusion and exclusion criteria, 48 papers were selected for review. These were read and reread, with 22 papers, including one thesis, selected for quality appraisal. One paper was discarded due to the exclusion criteria. Three major themes were evident from this study. First, students need assistance to develop tertiary level academic literacy skills when they commence their undergraduate nursing degree. Second, that teaching practices need to be consistent in both designing assessments and in giving feedback to students, in order to assist improvement of academic literacy skills. And finally, academic literacy can facilitate critical thinking when students are assessed using discipline specific genres that relate to their future professional nursing practice. This review highlights the importance of critical thinking in clinical nursing practice and its strong relationship with academic writing skills. It has shown critical thinking is discipline specific and nursing students need to be taught discipline specific literacy genres in undergraduate nursing degrees. Nursing has a diverse educational and cultural mix of students, and educators should not assume academic literacy skills upon commencement of an undergraduate nursing programme. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Implementation of immunochemical faecal occult blood test in general practice: a study protocol using a cluster-randomised stepped-wedge design.

PubMed

Juul, Jakob Søgaard; Bro, Flemming; Hornung, Nete; Andersen, Berit Sanne; Laurberg, Søren; Olesen, Frede; Vedsted, Peter

2016-07-11

Colorectal cancer is a common malignancy and a leading cause of cancer-related death. Half of patients with colorectal cancer initially present with non-specific or vague symptoms. In the need for a safe low-cost test, the immunochemical faecal occult blood test (iFOBT) may be part of the evaluation of such patients in primary care. Currently, Danish general practitioners have limited access to this test. The aim of this article is to describe a study that will assess the uptake and clinical use of iFOBT in general practice. Furthermore, it will investigate the diagnostic value and the clinical implications of using iFOBT in general practice on patients presenting with non-alarm symptoms of colorectal cancer. The study uses a cluster-randomised stepped-wedge design and is conducted in the Central Denmark Region among 836 GPs in 381 general practices. The municipalities of the Region and their appertaining general practitioners will be included sequentially in the study during the first 7 months of the 1-year study period. The following intervention has been developed for the study: a mandatory intervention providing all general practitioners with a starting package of 10 iFOBTs, a clinical instruction on iFOBT use in general practice and online information material from the date of inclusion, and an optional intervention consisting of a continuous medical education on colorectal cancer diagnostics and use of iFOBT. This study is among the first and largest trials to investigate the diagnostic use and the clinical value of iFOBT on patients presenting with non-alarm symptoms of colorectal cancer. The findings will be of national and international importance for the future planning of colorectal cancer diagnostics, particularly for 'low-risk-but-not-no-risk' patients with non-alarm symptoms of colorectal cancer. A Trial of the Implementation of iFOBT in General Practice NCT02308384 . Date of registration: 26 November 2014.

Clinical uses of brain natriuretic peptide in diagnosing and managing heart failure.

PubMed

Anderson, Kelley M

2008-06-01

To review current issues in the diagnosis, prognosis, and management of heart failure (HF), focusing on the clinical use of brain natriuretic peptide (BNP) as a diagnostic marker. Selective review of scientific literature and clinical practice guidelines. BNP is a useful clinical tool for the diagnosis, prognosis, and management of HF patients. Studies have consistently demonstrated high sensitivity, specificity, and negative predictive value of BNP levels in diagnostic situations. BNP cannot differentiate between systolic and diastolic HF. BNP can be used to assist in diagnosing HF in emergency and outpatient situations, particularly when the presenting symptom is dyspnea; determining HF prognosis, including predicting death and cardiac events; and potentially managing individuals with HF by determining safe discharge levels from acute care to avoid readmissions. BNP levels can vary depending on multiple confounders; therefore, clinical interpretation can be difficult.

Determination of clinically relevant content for a musculoskeletal anatomy curriculum for physical medicine and rehabilitation residents.

PubMed

Lisk, Kristina; Flannery, John F; Loh, Eldon Y; Richardson, Denyse; Agur, Anne M R; Woods, Nicole N

2014-01-01

To address the need for more clinical anatomy training in residency education, many postgraduate programs have implemented structured anatomy courses into their curriculum. Consensus often does not exist on specific content and level of detail of the content that should be included in such curricula. This article describes the use of the Delphi method to identify clinically relevant content to incorporate in a musculoskeletal anatomy curriculum for Physical Medicine and Rehabilitation (PM&R) residents. A two round modified Delphi involving PM&R experts was used to establish the curricular content. The anatomical structures and clinical conditions presented to the expert group were compiled using multiple sources: clinical musculoskeletal anatomy cases from the PM&R residency program at the University of Toronto; consultation with PM&R experts; and textbooks. In each round, experts rated the importance of each curricular item to PM&R residency education using a five-point Likert scale. Internal consistency (Cronbach's alpha) was used to determine consensus at the end of each round and agreement scores were used as an outcome measure to determine the content to include in the curriculum. The overall internal consistency in both rounds was 0.99. A total of 37 physiatrists from across Canada participated and the overall response rate over two rounds was 97%. The initial curricular list consisted of 361 items. After the second iteration, the list was reduced by 44%. By using a national consensus method we were able to objectively determine the relevant anatomical structures and clinical musculoskeletal conditions important in daily PM&R practice. © 2013 American Association of Anatomists.

Methodological strategies in using home sleep apnea testing in research and practice.

PubMed

Miller, Jennifer N; Schulz, Paula; Pozehl, Bunny; Fiedler, Douglas; Fial, Alissa; Berger, Ann M

2017-11-14

Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information. Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: "polysomnography," "home," "level III," "obstructive sleep apnea," and "out of center testing." Research articles that met inclusion criteria (n = 34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice. Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.

Surrogate Endpoint Evaluation: Principal Stratification Criteria and the Prentice Definition.

PubMed

Gilbert, Peter B; Gabriel, Erin E; Huang, Ying; Chan, Ivan S F

2015-09-01

A common problem of interest within a randomized clinical trial is the evaluation of an inexpensive response endpoint as a valid surrogate endpoint for a clinical endpoint, where a chief purpose of a valid surrogate is to provide a way to make correct inferences on clinical treatment effects in future studies without needing to collect the clinical endpoint data. Within the principal stratification framework for addressing this problem based on data from a single randomized clinical efficacy trial, a variety of definitions and criteria for a good surrogate endpoint have been proposed, all based on or closely related to the "principal effects" or "causal effect predictiveness (CEP)" surface. We discuss CEP-based criteria for a useful surrogate endpoint, including (1) the meaning and relative importance of proposed criteria including average causal necessity (ACN), average causal sufficiency (ACS), and large clinical effect modification; (2) the relationship between these criteria and the Prentice definition of a valid surrogate endpoint; and (3) the relationship between these criteria and the consistency criterion (i.e., assurance against the "surrogate paradox"). This includes the result that ACN plus a strong version of ACS generally do not imply the Prentice definition nor the consistency criterion, but they do have these implications in special cases. Moreover, the converse does not hold except in a special case with a binary candidate surrogate. The results highlight that assumptions about the treatment effect on the clinical endpoint before the candidate surrogate is measured are influential for the ability to draw conclusions about the Prentice definition or consistency. In addition, we emphasize that in some scenarios that occur commonly in practice, the principal strata sub-populations for inference are identifiable from the observable data, in which cases the principal stratification framework has relatively high utility for the purpose of effect modification analysis, and is closely connected to the treatment marker selection problem. The results are illustrated with application to a vaccine efficacy trial, where ACN and ACS for an antibody marker are found to be consistent with the data and hence support the Prentice definition and consistency.

Surrogate Endpoint Evaluation: Principal Stratification Criteria and the Prentice Definition

PubMed Central

Gilbert, Peter B.; Gabriel, Erin E.; Huang, Ying; Chan, Ivan S.F.

2015-01-01

A common problem of interest within a randomized clinical trial is the evaluation of an inexpensive response endpoint as a valid surrogate endpoint for a clinical endpoint, where a chief purpose of a valid surrogate is to provide a way to make correct inferences on clinical treatment effects in future studies without needing to collect the clinical endpoint data. Within the principal stratification framework for addressing this problem based on data from a single randomized clinical efficacy trial, a variety of definitions and criteria for a good surrogate endpoint have been proposed, all based on or closely related to the “principal effects” or “causal effect predictiveness (CEP)” surface. We discuss CEP-based criteria for a useful surrogate endpoint, including (1) the meaning and relative importance of proposed criteria including average causal necessity (ACN), average causal sufficiency (ACS), and large clinical effect modification; (2) the relationship between these criteria and the Prentice definition of a valid surrogate endpoint; and (3) the relationship between these criteria and the consistency criterion (i.e., assurance against the “surrogate paradox”). This includes the result that ACN plus a strong version of ACS generally do not imply the Prentice definition nor the consistency criterion, but they do have these implications in special cases. Moreover, the converse does not hold except in a special case with a binary candidate surrogate. The results highlight that assumptions about the treatment effect on the clinical endpoint before the candidate surrogate is measured are influential for the ability to draw conclusions about the Prentice definition or consistency. In addition, we emphasize that in some scenarios that occur commonly in practice, the principal strata sub-populations for inference are identifiable from the observable data, in which cases the principal stratification framework has relatively high utility for the purpose of effect modification analysis, and is closely connected to the treatment marker selection problem. The results are illustrated with application to a vaccine efficacy trial, where ACN and ACS for an antibody marker are found to be consistent with the data and hence support the Prentice definition and consistency. PMID:26722639

Doctors' perspectives on PSA testing illuminate established differences in prostate cancer screening rates between Australia and the UK: a qualitative study

PubMed Central

Pickles, Kristen; Carter, Stacy M; Rychetnik, Lucie; Entwistle, Vikki A

2016-01-01

Objectives To examine how general practitioners (GPs) in the UK and GPs in Australia explain their prostate-specific antigen (PSA) testing practices and to illuminate how these explanations are similar and how they are different. Design A grounded theory study. Setting Primary care practices in Australia and the UK. Participants 69 GPs in Australia (n=40) and the UK (n=29). We included GPs of varying ages, sex, clinical experience and patient populations. All GPs interested in participating in the study were included. Results GPs' accounts revealed fundamental differences in whether and how prostate cancer screening occurred in their practice and in the broader context within which they operate. The history of prostate screening policy, organisational structures and funding models appeared to drive more prostate screening in Australia and less in the UK. In Australia, screening processes and decisions were mostly at the discretion of individual clinicians, and varied considerably, whereas the accounts of UK GPs clearly reflected a consistent, organisationally embedded approach based on local evidence-based recommendations to discourage screening. Conclusions The GP accounts suggested that healthcare systems, including historical and current organisational and funding structures and rules, collectively contribute to how and why clinicians use the PSA test and play a significant role in creating the mindlines that GPs employ in their clinic. Australia's recently released consensus guidelines may support more streamlined and consistent care. However, if GP mindlines and thus routine practice in Australia are to shift, to ultimately reduce unnecessary or harmful prostate screening, it is likely that other important drivers at all levels of the screening process will need to be addressed. PMID:27920082

Development and validation of the brief esophageal dysphagia questionnaire.

PubMed

Taft, T H; Riehl, M; Sodikoff, J B; Kahrilas, P J; Keefer, L; Doerfler, B; Pandolfino, J E

2016-12-01

Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approach and further evaluation, including endoscopy. 1638 patients participated over two study phases. 744 participants completed the Brief Esophageal Dysphagia Questionnaire (BEDQ) for phase 1; 869 completed the BEDQ, Visceral Sensitivity Index, Gastroesophageal Reflux Disease Questionnaire, and Hospital Anxiety and Depression Scale for phase 2. Demographic and clinical data were obtained via the electronic medical record. The BEDQ was evaluated for internal consistency, split-half reliability, ceiling and floor effects, and construct validity. The BEDQ demonstrated excellent internal consistency, reliability, and construct validity. The symptom frequency and severity scales scored above the standard acceptable cutoffs for reliability while the impaction subscale yielded poor internal consistency and split-half reliability; thus the impaction items were deemed qualifiers only and removed from the total score. No significant ceiling or floor effects were found with the exception of 1 item, and inter-item correlations fell within accepted ranges. Construct validity was supported by moderate yet significant correlations with other measures. The predictive ability of the BEDQ was small but significant. The BEDQ represents a rapid, reliable, and valid assessment tool for esophageal dysphagia with food impaction for clinical practice that differentiates between patients with major motor dysfunction and mechanical obstruction. © 2016 John Wiley & Sons Ltd.

Development and Validation of the Brief Esophageal Dysphagia Questionnaire

PubMed Central

Taft, Tiffany H.; Riehl, Megan; Sodikoff, Jamie B.; Kahrilas, Peter J.; Keefer, Laurie; Doerfler, Bethany; Pandolfino, John E.

2017-01-01

Background Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approach and further evaluation, including endoscopy. Methods 1,638 patients participated over two study phases. 744 participants completed the Brief Esophageal Dysphagia Questionnaire (BEDQ) for phase 1; 869 completed the BEDQ, Visceral Sensitivity Index, Gastroesophageal Reflux Disease Questionnaire, and Hospital Anxiety and Depression Scale for phase 2. Demographic and clinical data were obtained via the electronic medical record. The BEDQ was evaluated for internal consistency, split-half reliability, ceiling and floor effects, and construct validity. Key Results The BEDQ demonstrated excellent internal consistency, reliability, and construct validity. The symptom frequency and severity scales scored above the standard acceptable cutoffs for reliability while the impaction subscale yielded poor internal consistency and split-half reliability; thus the impaction items were deemed qualifiers only and removed from the total score. No significant ceiling or floor effects were found with the exception of 1 item, and inter-item correlations fell within accepted ranges. Construct validity was supported by moderate yet significant correlations with other measures. The predictive ability of the BEDQ was small but significant. Conclusions & Inferences The BEDQ represents a rapid, reliable and valid assessment tool for esophageal dysphagia with food impaction for clinical practice that differentiates between patients with major motor dysfunction and mechanical obstruction. PMID:27380834

Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians.

PubMed

Morton, Suzanne; Shih, Sarah C; Winther, Chloe H; Tinoco, Aldo; Kessler, Rodger S; Scholle, Sarah Hudson

2015-01-01

Health information technology (IT) offers promising tools for improving care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medicaid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards. We surveyed physician-owned and hospital/health system-affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their importance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities. Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to support care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice's capacity for systematic change. Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians' priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination. © 2015 Annals of Family Medicine, Inc.

Development and Psychometric Properties of the Nursing Critical Thinking in Clinical Practice Questionnaire.

PubMed

Zuriguel-Pérez, Esperanza; Falcó-Pegueroles, Anna; Roldán-Merino, Juan; Agustino-Rodriguez, Sandra; Gómez-Martín, Maria Del Carmen; Lluch-Canut, Maria Teresa

2017-08-01

A complex healthcare environment, with greater need for care based on the patient and evidence-based practice, are factors that have contributed to the increased need for critical thinking in professional competence. At the theoretical level, Alfaro-LeFevre () put forward a model of critical thinking made up of four components. And although these explain the construct, instruments for their empirical measurement are lacking. The purpose of the study was to develop and validate the psychometric properties of an instrument, the Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 Practice), designed to evaluate the critical thinking abilities of nurses in the clinical setting. A cross-sectional survey design was used. A pool of items was generated for evaluation by a panel of experts who considered their validity for the new instrument, which was finally made up of 109 items. Following this, validation was carried out using a sample of 339 nurses at a hospital in Barcelona, Spain. Reliability was determined by means of internal consistency and test-retest stability over time, although the validity of the construct was assessed by means of confirmatory factor analysis. The content validity index of the N-CT-4 Practice was .85. Cronbach's alpha coefficient for the whole instrument was .96. The intraclass correlation coefficient was .77. Confirmatory factor analysis showed that the instrument was in line with the four-dimensional model proposed by Alfaro-LeFevre (). The psychometric properties of theN-CT-4 Practice uphold its potential for use in measuring critical thinking and in future research related with the examination of critical thinking. © 2017 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.

Educating Mental Health Clinicians About Sensory Modulation to Enhance Clinical Practice in a Youth Acute Inpatient Mental Health Unit: A Feasibility Study.

PubMed

Blackburn, Julie; McKenna, Brian; Jackson, Brian; Hitch, Danielle; Benitez, Jessica; McLennan, Cathy; Furness, Trentham

2016-07-01

There is an emergence of literature describing effective sensory modulation (SM) interventions to de-escalate violence and aggression among mental health inpatients. However, the evidence is limited to adult settings, with the effect of SM in youth acute settings unknown. Yet, before SM may be used as a de-escalation intervention in youth acute settings, multidisciplinary staff need to be educated about and supported in the clinical application of SM. In the current study, an online SM education package was developed to assist mental health staff understand SM. This was blended with action learning sets (ALS), small group experiential opportunities consisting staff and consumers to learn about SM resources, and the support of SM trained nurses. The aims of the study were to evaluate the effectiveness of this SM education intervention in (a) transferring knowledge of SM to staff, and (b) translating this knowledge into practice in a youth acute inpatient mental health unit. A mixed methods research design with an 11-item pre- and post-education questionnaire was used along with three-month follow-up focus groups. The SM education improved understanding about SM (all 11-items p ≤ 0.004, r ≥ 0.47). Three-months after SM education, four themes evident in the focus group data emerged about the practice and process of SM; (1) translating of learning into practice, (2) SM in practice, (3) perceptions of SM benefits, and (4) limitations of SM. A blended SM education process enhanced clinical practice in the unit, yet participants were mindful of limitations of SM in situations of distress or escalating agitation.

A systematic review of team formulation in clinical psychology practice: Definition, implementation, and outcomes.

PubMed

Geach, Nicole; Moghaddam, Nima G; De Boos, Danielle

2018-06-01

Team formulation is promoted by professional practice guidelines for clinical psychologists. However, it is unclear whether team formulation is understood/implemented in consistent ways - or whether there is outcome evidence to support the promotion of this practice. This systematic review aimed to (1) synthesize how team formulation practice is defined and implemented by practitioner psychologists and (2) analyse the range of team formulation outcomes in the peer-reviewed literature. Seven electronic bibliographic databases were searched in June 2016. Eleven articles met inclusion criteria and were quality assessed. Extracted data were synthesized using content analysis. Descriptions of team formulation revealed three main forms of instantiation: (1) a structured, consultation approach; (2) semi-structured, reflective practice meetings; and (3) unstructured/informal sharing of ideas through routine interactions. Outcome evidence linked team formulation to a range of outcomes for staff teams and service users, including some negative outcomes. Quality appraisal identified significant issues with evaluation methods; such that, overall, outcomes were not well-supported. There is weak evidence to support the claimed beneficial outcomes of team formulation in practice. There is a need for greater specification and standardization of 'team formulation' practices, to enable a clearer understanding of any relationships with outcomes and implications for best-practice implementations. Under the umbrella term of 'team formulation', three types of practice are reported: (1) highly structured consultation; (2) reflective practice meetings; and (3) informal sharing of ideas. Outcomes linked to team formulation, including some negative outcomes, were not well evidenced. Research using robust study designs is required to investigate the process and outcomes of team formulation practice. © 2017 The British Psychological Society.

'Seeking authorization': a grounded theory exploration of mentors' experiences of assessing nursing students on the borderline of achievement of competence in clinical practice.

PubMed

Cassidy, Simon; Coffey, Michael; Murphy, Fiona

2017-09-01

To develop a substantive theoretical explanation of how mentors make sense of their experiences where nursing students are on the borderline of achievement of competence in clinical practice. The reluctance of Registered Nurse mentors to fail nursing students in clinical practice despite concerns about competence remains a contemporary issue in international healthcare education. Mentors' assessment decisions have considerable impact for a variety of key stakeholders, not least for students in these circumstances. Grounded theory qualitative study. Phase one involved 20 individual semi-structured interviews with nurse mentors in one United Kingdom National Health Service Health Board (July-October 2009). Phase two included eight individual semi-structured interviews and seven focus groups with mentors and practice educators (n = 38) in four further Health Boards (June 2011-February 2012). Data were analysed using open, axial and selective coding consistent with grounded theory method. Three categories 'the conundrum of practice competence,' 'the intensity of nurturing hopefulness,' and 'managing assessment impasse,' led to the study's substantive theoretical explanation - 'Seeking authorization: Establishing collective accountability for mentorship.' This demonstrates how mentors are dependent on key sources of support and feedback to validate their assessment decision-making, notwithstanding substantial personal, professional and organizational pressures. We conclude that management of borderline assessment situations is considerably developed by recognition of the authorizing effects of a wider community of assessors. Consequently, we identify the personal, professional and organizational implications involved in the preparation, support and regulation of mentors specifically during borderline assessment circumstances. © 2017 John Wiley & Sons Ltd.

Economic evaluation of an implementation strategy for the management of low back pain in general practice.

PubMed

Jensen, Cathrine Elgaard; Riis, Allan; Petersen, Karin Dam; Jensen, Martin Bach; Pedersen, Kjeld Møller

2017-05-01

In connection with the publication of a clinical practice guideline on the management of low back pain (LBP) in general practice in Denmark, a cluster randomised controlled trial was conducted. In this trial, a multifaceted guideline implementation strategy to improve general practitioners' treatment of patients with LBP was compared with a usual implementation strategy. The aim was to determine whether the multifaceted strategy was cost effective, as compared with the usual implementation strategy. The economic evaluation was conducted as a cost-utility analysis where cost collected from a societal perspective and quality-adjusted life years were used as outcome measures. The analysis was conducted as a within-trial analysis with a 12-month time horizon consistent with the follow-up period of the clinical trial. To adjust for a priori selected covariates, generalised linear models with a gamma family were used to estimate incremental costs and quality-adjusted life years. Furthermore, both deterministic and probabilistic sensitivity analyses were conducted. Results showed that costs associated with primary health care were higher, whereas secondary health care costs were lower for the intervention group when compared with the control group. When adjusting for covariates, the intervention was less costly, and there was no significant difference in effect between the 2 groups. Sensitivity analyses showed that results were sensitive to uncertainty. In conclusion, the multifaceted implementation strategy was cost saving when compared with the usual strategy for implementing LBP clinical practice guidelines in general practice. Furthermore, there was no significant difference in effect, and the estimate was sensitive to uncertainty.

Practices for Identifying and Rejecting Hemolyzed Specimens Are Highly Variable in Clinical Laboratories.

PubMed

Howanitz, Peter J; Lehman, Christopher M; Jones, Bruce A; Meier, Frederick A; Horowitz, Gary L

2015-08-01

Hemolysis is an important clinical laboratory quality attribute that influences result reliability. To determine hemolysis identification and rejection practices occurring in clinical laboratories. We used the College of American Pathologists Survey program to distribute a Q-Probes-type questionnaire about hemolysis practices to Chemistry Survey participants. Of 3495 participants sent the questionnaire, 846 (24%) responded. In 71% of 772 laboratories, the hemolysis rate was less than 3.0%, whereas in 5%, it was 6.0% or greater. A visual scale, an instrument scale, and combination of visual and instrument scales were used to identify hemolysis in 48%, 11%, and 41% of laboratories, respectively. A picture of the hemolysis level was used as an aid to technologists' visual interpretation of hemolysis levels in 40% of laboratories. In 7.0% of laboratories, all hemolyzed specimens were rejected; in 4% of laboratories, no hemolyzed specimens were rejected; and in 88% of laboratories, some specimens were rejected depending on hemolysis levels. Participants used 69 different terms to describe hemolysis scales, with 21 terms used in more than 10 laboratories. Slight and moderate were the terms used most commonly. Of 16 different cutoffs used to reject hemolyzed specimens, moderate was the most common, occurring in 30% of laboratories. For whole blood electrolyte measurements performed in 86 laboratories, 57% did not evaluate the presence of hemolysis, but for those that did, the most common practice in 21 laboratories (24%) was centrifuging and visually determining the presence of hemolysis in all specimens. Hemolysis practices vary widely. Standard assessment and consistent reporting are the first steps in reducing interlaboratory variability among results.

Implementation of a School-wide Clinical Intervention Documentation System

PubMed Central

Stevenson, T. Lynn; Fox, Brent I.; Andrus, Miranda; Carroll, Dana

2011-01-01

Objective. To evaluate the effectiveness and impact of a customized Web-based software program implemented in 2006 for school-wide documentation of clinical interventions by pharmacy practice faculty members, pharmacy residents, and student pharmacists. Methods. The implementation process, directed by a committee of faculty members and school administrators, included preparation and refinement of the software, user training, development of forms and reports, and integration of the documentation process within the curriculum. Results. Use of the documentation tool consistently increased from May 2007 to December 2010. Over 187,000 interventions were documented with over $6.2 million in associated cost avoidance. Conclusions. Successful implementation of a school-wide documentation tool required considerable time from the oversight committee and a comprehensive training program for all users, with ongoing monitoring of data collection practices. Data collected proved to be useful to show the impact of faculty members, residents, and student pharmacists at affiliated training sites. PMID:21829264

The potential of disease management for neuromuscular hereditary disorders.

PubMed

Chouinard, Maud-Christine; Gagnon, Cynthia; Laberge, Luc; Tremblay, Carmen; Côté, Charlotte; Leclerc, Nadine; Mathieu, Jean

2009-01-01

Neuromuscular hereditary disorders require long-term multidisciplinary rehabilitation management. Although the need for coordinated healthcare management has long been recognized, most neuromuscular disorders are still lacking clinical guidelines about their long-term management and structured evaluation plan with associated services. One of the most prevalent adult-onset neuromuscular disorders, myotonic dystrophy type 1, generally presents several comorbidities and a variable clinical picture, making management a constant challenge. This article presents a healthcare follow-up plan and proposes a nursing case management within a disease management program as an innovative and promising approach. This disease management program and model consists of eight components including population identification processes, evidence-based practice guidelines, collaborative practice, patient self-management education, and process outcomes evaluation (Disease Management Association of America, 2004). It is believed to have the potential to significantly improve healthcare management for neuromuscular hereditary disorders and will prove useful to nurses delivering and organizing services for this population.

Student attitudes to psychiatry and their clinical placements.

PubMed

Budd, Simon; Kelley, Rachael; Day, Richard; Variend, Hannele; Dogra, Nisha

2011-01-01

Medical students consistently report low rates of interest in psychiatry as a career over time with negative perceptions of the specialty. Only 3-6% of students enter the specialty. To explore medical students' current career choices and attitudes to psychiatry and factors affecting these. Medical students at four UK medical schools completed a questionnaire related to career specialty choices and psychiatry and their psychiatry placement experiences. A total of 905 questionnaires were returned. Psychiatry was first career specialty choice in 4% but in the top three choices in 14%. The students in this group who had undertaken clinical placements were more positively inclined towards psychiatry, given more opportunities to practice and receive feedback on psychiatric skills, and more inclined to practice psychiatry later. One in seven students is interested in psychiatry. Psychiatrists need to find ways to identify these students and target them with individually tailored interventions to help recruitment into the specialty.

Objective Data Assessment (ODA) Methods as Nutritional Assessment Tools.

PubMed

Hamada, Yasuhiro

2015-01-01

Nutritional screening and assessment should be a standard of care for all patients because nutritional management plays an important role in clinical practice. However, there is no gold standard for the diagnosis of malnutrition or undernutrition, although a large number of nutritional screening and assessment tools have been developed. Nutritional screening and assessment tools are classified into two categories, namely, subjective global assessment (SGA) and objective data assessment (ODA). SGA assesses nutritional status based on the features of medical history and physical examination. On the other hand, ODA consists of objective data provided from various analyses, such as anthropometry, bioimpedance analysis (BIA), dual-energy X-ray absorptiometry (DEXA), computed tomography (CT), magnetic resonance imaging (MRI), laboratory tests, and functional tests. This review highlights knowledge on the performance of ODA methods for the assessment of nutritional status in clinical practice. J. Med. Invest. 62: 119-122, August, 2015.

Strategies to translate knowledge related to common musculoskeletal conditions into physiotherapy practice: a systematic review.

PubMed

Bérubé, Marie-Ève; Poitras, Stéphane; Bastien, Marc; Laliberté, Lydie-Anne; Lacharité, Anyck; Gross, Douglas P

2018-03-01

Many physiotherapists underuse evidence-based practice guidelines or recommendations when treating patients with musculoskeletal disorders, yet synthesis of knowledge translation interventions used within the field of physiotherapy fails to offer clear conclusions to guide the implementation of clinical practice guidelines. To evaluate the effectiveness of various knowledge translation interventions used to implement changes in the practice of current physiotherapists treating common musculoskeletal issues. A computerized literature search of MEDLINE, CINHAL and ProQuest of systematic reviews (from inception until May 2016) and primary research studies (from January 2010 until June 2016). Eligibility criteria specified articles evaluating interventions for translating knowledge into physiotherapy practice. Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Of a total of 13014 articles located and titles and abstracts screened, 34 studies met the inclusion criteria, including three overlapping publications, resulting in 31 individual studies. Knowledge translation interventions appear to have resulted in a positive change in physiotherapist beliefs, attitudes, skills and guideline awareness. However, no consistent improvement in clinical practice, patient and economic outcomes were observed. The studies included had small sample sizes and low methodological quality. The heterogeneity of the studies was not conducive to pooling the data. The intensity and type of knowledge translation intervention seem to have an effect on practice change. More research targeting financial, organizational and regulatory knowledge translation interventions is needed. Copyright © 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Evidence-based practice: beliefs, attitudes, knowledge, and skills among Colombian physical therapists.

PubMed

Ramírez-Vélez, Robinson; Correa-Bautista, Jorge Enrique; Muñoz-Rodríguez, Diana Isabel; Ramírez, Lorena; González-Ruíz, Katherine; Domínguez-Sánchez, María Andrea; Durán-Palomino, Diana; Girabent-Farrés, Montserrat; Flórez-López, María Eugenia; Bagur-Calafat, M Caridad

2015-01-01

The main purpose of this study was to describe a group of Colombian physical therapists' beliefs and attitudes towards Evidence-Based Practice (EBP), their education, knowledge and skills for implementing EBP, the use of relevant literature in clinical practice, access to and availability of scientific information and perceived barriers to including EBP in practice. This was a cross-sectional study which involved 1,064 Colombian physical therapists. The study used a 50-item screening questionnaire EBP developed to estimate attitudes, beliefs, knowledge and skills regarding. This instrument has been adapted and was validated previously in Colombia by Flórez-López et al. The population mostly consisted of young females (77.2%) aged 22 to 29 years old (79.4%). Most respondents had an undergraduate degree (87.7%). The physical therapists stated that they had positive attitudes and beliefs regarding EBP, most of them answering that they agreed or strongly agreed that EBP is necessary (71.6%), the relevant literature is useful for practice (61.3%), EBP improves the quality of patient care (64.1%) and evidence helps in decision-making (44.5%). Forty-one percent of the respondents indicated that a lack of research skills was the most important barrier to the use of evidence in practice. The physical therapists reported that they had a positive attitude to EBP and were interested in learning about or improving the skills necessary to adopt EBP in their clinical practice.

Evidence-based practice: beliefs, attitudes, knowledge, and skills among Colombian physical therapists

PubMed Central

Correa-Bautista, Jorge Enrique; Muñoz-Rodríguez, Diana Isabel; Ramírez, Lorena; González-Ruíz, Katherine; Domínguez-Sánchez, María Andrea; Durán-Palomino, Diana; Girabent-Farrés, Montserrat; Flórez-López, María Eugenia; Bagur-Calafat, M Caridad

2015-01-01

Objective: The main purpose of this study was to describe a group of Colombian physical therapists' beliefs and attitudes towards Evidence-Based Practice (EBP), their education, knowledge and skills for implementing EBP, the use of relevant literature in clinical practice, access to and availability of scientific information and perceived barriers to including EBP in practice. Methods: This was a cross-sectional study which involved 1,064 Colombian physical therapists. The study used a 50-item screening questionnaire EBP developed to estimate attitudes, beliefs, knowledge and skills regarding. This instrument has been adapted and was validated previously in Colombia by Flórez-López et al. Results: The population mostly consisted of young females (77.2%) aged 22 to 29 years old (79.4%). Most respondents had an undergraduate degree (87.7%). The physical therapists stated that they had positive attitudes and beliefs regarding EBP, most of them answering that they agreed or strongly agreed that EBP is necessary (71.6%), the relevant literature is useful for practice (61.3%), EBP improves the quality of patient care (64.1%) and evidence helps in decision-making (44.5%). Forty-one percent of the respondents indicated that a lack of research skills was the most important barrier to the use of evidence in practice. Conclusion: The physical therapists reported that they had a positive attitude to EBP and were interested in learning about or improving the skills necessary to adopt EBP in their clinical practice. PMID:26019383

2016 AAHA/IAAHPC End-of-Life Care Guidelines.

PubMed

Bishop, Gail; Cooney, Kathleen; Cox, Shea; Downing, Robin; Mitchener, Kathy; Shanan, Amir; Soares, Nancy; Stevens, Brenda; Wynn, Tammy

End-of-life (EOL) care and decisionmaking embody the critical final stage in a pet's life and are as important and meaningful as the sum of the clinical care provided for all prior life stages. EOL care should focus on maximizing patient comfort and minimizing suffering while providing a collaborative and supportive partnership with the caregiver client. Timely, empathetic, and nonjudgmental communication is the hallmark of effective client support. Veterinarians should not allow an EOL patient to succumb to a natural death without considering the option of euthanasia and ensuring that other measures to alleviate discomfort and distress are in place. Animal hospice care addresses the patient's unique emotional and social needs as well as the physical needs traditionally treated in clinical practice. An EOL treatment plan should consist of client education; evaluating the caregiver's needs and goals for the pet; and a collaborative, personalized, written treatment plan involving the clinical staff and client. Primary care practices should have a dedicated team to implement palliative and hospice care for EOL patients. How the healthcare team responds to a client's grief after the loss of a pet can be a key factor in the client's continued loyalty to the practice. Referral to professional grief-support counseling can be a helpful option in this regard.

American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients--2002 update.

PubMed

Petak, Steven M; Nankin, Howard R; Spark, Richard F; Swerdloff, Ronald S; Rodriguez-Rigau, Luis J

2002-01-01

In these clinical practice guidelines, specific recommendations are made for determining the most effective methods of diagnosing and treating hypogonadism in adult male patients. The target populations for these guidelines include the following: (1) men with primary testicular failure requiring testosterone replacement (hypergonadotropic hypogonadism); (2) male patients with gonadotropin deficiency or dysfunction who may have received testosterone replacement therapy or treatment for infertility (hypogonadotropic hypogonadism); and (3) aging men with symptoms relating to testosterone deficiency who could benefit from testosterone replacement therapy. Initial hormonal evaluation generally consists of a testosterone determination, in conjunction with a free testosterone or sex hormone-binding globulin level, inpatients with clear symptoms and signs but normal-range total testosterone, follicle-stimulating hormone, luteinizing hormone, and prolactin levels. Other possible tests include semen analysis, pituitary imaging studies, genetic studies, bone densitometry, testicular ultrasonography,testicular biopsy, and specialized hormonal dynamic testing. Therapeutic options generally consist of testosterone replacement by injections, patches, or topically applied gel in hypergonadotropic patients and in hypogonadotropic patients not interested in fertility. In hypogonadotropic patients interested in fertility, gonadal stimulation option scan be considered, including human chorionic gonadotropin stimulation therapy with or without human menopausal gonadotropin (or follicle-stimulating hormone) or gonadotropin-releasing hormone pump therapy. These therapies may be combined with assisted reproductive technologies such as in vitro fertilization with intracytoplasmic sperm injection, which may allow pregnancy to occur with very low numbers of sperm.

Implementing clinical protocols in oncology: quality gaps and the learning curve phenomenon.

PubMed

Kedikoglou, Simos; Syrigos, Konstantinos; Skalkidis, Yannis; Ploiarchopoulou, Fani; Dessypris, Nick; Petridou, Eleni

2005-08-01

The quality improvement effort in clinical practice has focused mostly on 'performance quality', i.e. on the development of comprehensive, evidence-based guidelines. This study aimed to assess the 'conformance quality', i.e. the extent to which guidelines once developed are correctly and consistently applied. It also aimed to assess the existence of quality gaps in the treatment of certain patient segments as defined by age or gender and to investigate methods to improve overall conformance quality. A retrospective audit of clinical practice in a well-defined oncology setting was undertaken and the results compared to those obtained from prospectively applying an internally developed clinical protocol in the same setting and using specific tools to increase conformance quality. All indicators showed improvement after the implementation of the protocol that in many cases reached statistical significance, while in the entire cohort advanced age was associated (although not significantly) with sub-optimal delivery of care. A 'learning curve' phenomenon in the implementation of quality initiatives was detected, with all indicators improving substantially in the second part of the prospective study. Clinicians should pay separate attention to the implementation of chosen protocols and employ specific tools to increase conformance quality in patient care.

The melatonergic system in mood and anxiety disorders and the role of agomelatine: implications for clinical practice.

PubMed

De Berardis, Domenico; Marini, Stefano; Fornaro, Michele; Srinivasan, Venkataramanujam; Iasevoli, Felice; Tomasetti, Carmine; Valchera, Alessandro; Perna, Giampaolo; Quera-Salva, Maria-Antonia; Martinotti, Giovanni; di Giannantonio, Massimo

2013-06-13

Melatonin exerts its actions through membrane MT1/MT2 melatonin receptors, which belong to the super family of G-protein-coupled receptors consisting of the typical seven transmembrane domains. MT1 and MT2 receptors are expressed in various tissues of the body either as single ones or together. A growing literature suggests that the melatonergic system may be involved in the pathophysiology of mood and anxiety disorders. In fact, some core symptoms of depression show disturbance of the circadian rhythm in their clinical expression, such as diurnal mood and other symptomatic variation, or are closely linked to circadian system functioning, such as sleep-wake cycle alterations. In addition, alterations have been described in the circadian rhythms of several biological markers in depressed patients. Therefore, there is interest in developing antidepressants that have a chronobiotic effect (i.e., treatment of circadian rhythm disorders). As melatonin produces chronobiotic effects, efforts have been aimed at developing agomelatine, an antidepressant with melatonin agonist activity. The present paper reviews the role of the melatonergic system in the pathophysiology of mood and anxiety disorders and the clinical characteristics of agomelatine. Implications of agomelatine in "real world" clinical practice will be also discussed.

Combining interdisciplinary and International Medical Graduate perspectives to teach clinical and ethical communication using multimedia.

PubMed

Woodward-Kron, Robyn; Flynn, Eleanor; Delany, Clare

2011-01-01

In Australia, international medical graduates (IMGs) play a crucial role in addressing workforce shortages in healthcare. Their ability to deliver safe and effective healthcare in an unfamiliar cultural setting is intrinsically tied to effective communication. Hospital-based medical clinical educators, who play an important role in providing communication training to IMGs, would benefit from practical resources and an understanding of the relevant pedagogies to address these issues in their teaching. This paper examines the nature of an interdisciplinary collaboration to develop multimedia resources for teaching clinical and ethical communication to IMGs. We describe the processes and dynamics of the collaboration, and outline the methodologies from applied linguistics, medical education, and health ethics that we drew upon. The multimedia consist of three video clips of challenging communication scenarios as well as experienced IMGs talking about communication and ethics. The multimedia are supported by teaching guidelines that address relevant disciplinary concerns of the three areas of collaboration. In the paper's discussion we point out the pre-conditions that facilitated the interdisciplinary collaboration. We propose that such collaborative approaches between the disciplines and participants can provide new perspectives to address the multifaceted challenges of clinical teaching and practice.

Appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in eastern Iowa.

PubMed

Iben, P; Kanellis, M J; Warren, J

2000-01-01

The purpose of this prospective study was to assess the appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in three Eastern Iowa practices. During the month of October 1998, a tally was kept of all patient appointments at a private pediatric dental office, a public health dental clinic, and a university-based pediatric dentistry clinic. Patients were categorized as either Medicaid or non-Medicaid. Appointment behavior categories were defined as: On time; Failure; Late-notice Cancellation (less than 24 hours notice); and Tardy (greater than 10 minutes). The data was entered in SPSS and analyzed using the chi square statistic. Statistical significance was P < 0.05. A total of 1,406 appointments were recorded for all three sites. Overall, patients on Iowa Medicaid had higher appointment failure, late-notice cancellation, and tardiness rates than non-Medicaid patients at all three clinics. However, these differences were only statistically significant for the private office and the university-based clinic. Failed appointment rates for Medicaid patients were much higher at the private office (38%) than at the other two sites. Consistent with anecdotal reports from dentists, Medicaid patients had higher rates of broken appointments than did non-Medicaid patients, particularly in a private practice setting.

Pharmacogenetics and pharmacogenomics in psoriasis treatment: current challenges and future prospects.

PubMed

Sutherland, Alison; Power, Rebecca J; Rahman, Proton; O'Rielly, Darren D

2016-08-01

Topical, systemic, oral disease modifying, and biologic agents are part of the armamentarium to manage psoriatic disease. The choice of therapy depends upon disease severity, relevant co-morbidities and patient preference. There is great variability in patient response with these agents, and there is still no clear method of selecting the preferred therapeutic agent for efficacy or lack of adverse events. This article will review the pharmacogenetic and pharmacogenomic targets that are currently known with respect to psoriasis vulgaris, and the most frequent co-morbidity of psoriasis, psoriatic arthritis. Presently, no clinically actionable biomarker exists for any therapeutic agent used to treat psoriasis or psoriatic arthritis. The lack of validated outcome measures and conflicting results of open-label studies conducted may be attributed to a multitude of issues that confound discovery. Consequently, studies have been underpowered to identify genes or genetic variants worth translating to clinical practice. In order to achieve a pharmacogenetic/pharmacogenomic signature, improvements in study design of future investigations are required, including carefully designed prospective studies. It is imperative to combine known clinical, serological, and molecular markers with consistent outcomes and an adequate health economic evaluation before they can be adopted widely in clinical practice.

The Full Spectrum of Clinical Ethical Issues in Kidney Failure. Findings of a Systematic Qualitative Review.

PubMed

Kahrass, Hannes; Strech, Daniel; Mertz, Marcel

2016-01-01

When treating patients with kidney failure, unavoidable ethical issues often arise. Current clinical practice guidelines some of them, but lack comprehensive information about the full range of relevant ethical issues in kidney failure. A systematic literature review of such ethical issues supports medical professionalism in nephrology, and offers a solid evidential base for efforts that aim to improve ethical conduct in health care. To identify the full spectrum of clinical ethical issues that can arise for patients with kidney failure in a systematic and transparent manner. A systematic review in Medline (publications in English or German between 2000 and 2014) and Google Books (with no restrictions) was conducted. Ethical issues were identified by qualitative text analysis and normative analysis. The literature review retrieved 106 references that together mentioned 27 ethical issues in clinical care of kidney failure. This set of ethical issues was structured into a matrix consisting of seven major categories and further first and second-order categories. The systematically-derived matrix helps raise awareness and understanding of the complexity of ethical issues in kidney failure. It can be used to identify ethical issues that should be addressed in specific training programs for clinicians, clinical practice guidelines, or other types of policies dealing with kidney failure.

The Full Spectrum of Clinical Ethical Issues in Kidney Failure. Findings of a Systematic Qualitative Review

PubMed Central

Kahrass, Hannes; Strech, Daniel; Mertz, Marcel

2016-01-01

Background When treating patients with kidney failure, unavoidable ethical issues often arise. Current clinical practice guidelines some of them, but lack comprehensive information about the full range of relevant ethical issues in kidney failure. A systematic literature review of such ethical issues supports medical professionalism in nephrology, and offers a solid evidential base for efforts that aim to improve ethical conduct in health care. Aim To identify the full spectrum of clinical ethical issues that can arise for patients with kidney failure in a systematic and transparent manner. Method A systematic review in Medline (publications in English or German between 2000 and 2014) and Google Books (with no restrictions) was conducted. Ethical issues were identified by qualitative text analysis and normative analysis. Results The literature review retrieved 106 references that together mentioned 27 ethical issues in clinical care of kidney failure. This set of ethical issues was structured into a matrix consisting of seven major categories and further first and second-order categories. Conclusions The systematically-derived matrix helps raise awareness and understanding of the complexity of ethical issues in kidney failure. It can be used to identify ethical issues that should be addressed in specific training programs for clinicians, clinical practice guidelines, or other types of policies dealing with kidney failure. PMID:26938863

Clinical effectiveness and safety of vildagliptin in >19 000 patients with type 2 diabetes: the GUARD study.

PubMed

Rosales, R; Abou Jaoude, E; Al-Arouj, M; Fawwad, A; Orabi, A; Shah, P; DiTommaso, S; Vaz, J; Latif, Z A

2015-06-01

The present GUARD study was a prospective, non-interventional study evaluating the clinical effectiveness, safety and tolerability of vildagliptin with or without metformin in adult patients with type 2 diabetes mellitus (T2DM) studied in routine clinical practice. Patients were enrolled from countries across four geographical regions. The primary endpoint was change in glycated haemoglobin (HbA1c) concentration from baseline after 24 weeks of treatment with vildagliptin with or without metformin. Of 19 331 patients analysed, 3511 received vildagliptin and 15 820 received vildagliptin plus metformin. At week 24, the mean HbA1c was reduced significantly from baseline by -1.27% (vildagliptin: -1.17%; vildagliptin plus metformin: -1.29%; p < 0.0001). Significant reductions in HbA1c from baseline were consistently reported regardless of patient age, body mass index (BMI) or baseline HbA1c. Weight and BMI were also significantly reduced from baseline. Vildagliptin treatment with or without metformin was generally well tolerated. It provided clinically relevant glycaemic and weight control, and was well tolerated in a large multi-ethnic population of patients with T2DM studied in routine clinical practice. © 2015 John Wiley & Sons Ltd.

Physician 'defiance' towards hand hygiene compliance: Is there a theory-practice-ethics gap?

PubMed

Mortell, Manfred; Balkhy, Hanan H; Tannous, Elias B; Jong, Mei Thiee

2013-07-01

The theory-practice gap has always existed [1,2]. This gap is often cited as a culmination of theory being idealistic and impractical, even if practical and beneficial, is often ignored. Most of the evidence relating to the non-integration of theory and practice assumes that environmental factors are responsible and will affect learning and practice outcomes, hence the gap. Therefore, the author believes that to 'bridge the gap' between theory and practice, an additional dimension is required: ethics. A moral duty and obligation ensuring theory and practice integrate. In order to effectively implement new practices, one must deem these practices as worthy and relevant to their role as healthcare providers (HCP). Hence, this introduces a new concept which the author refers to as the theory-practice-ethics gap. This theory-practice-ethics gap must be considered when reviewing some of the unacceptable outcomes in healthcare practice [3]. The literature suggests that there is a crisis of ethics where theory and practice integrate, and healthcare providers are failing to fulfill our duty as patient advocates. Physician hand hygiene practices and compliance at King Abdulaziz Cardiac Centre (KACC) are consistent with those of other physicians in the global healthcare arena. That is one of noncompliance to King Abdulaziz Medical City (KAMC) organizational expectations and the World Health Organization (WHO) requirements? An observational study was conducted on the compliance of cardiac surgeons, cardiologists and nurses in the authors' cardiac center from January 2010 to December 2011. The hand hygiene (HH) compliance elements that were evaluated pertained to the WHO's five moments of HH recommendations. The data was obtained through direct observation by KAMC infection prevention and control practitioners. Physician hand hygiene compliance at KACC was consistently less than 60%, with nurses regularly encouraging physicians to be diligent with hand hygiene practices in the clinical area. Hand hygiene compliance will not improve unless evidence-based recommendations are adopted and endorsed by all healthcare professionals and providers.

Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology.

PubMed

Esposito, Pasquale; Dal Canton, Antonio

2014-11-06

Evaluation and improvement of quality of care provided to the patients are of crucial importance in the daily clinical practice and in the health policy planning and financing. Different tools have been developed, including incident analysis, health technology assessment and clinical audit. The clinical audit consist of measuring a clinical outcome or a process, against well-defined standards set on the principles of evidence-based medicine in order to identify the changes needed to improve the quality of care. In particular, patients suffering from chronic renal diseases, present many problems that have been set as topics for clinical audit projects, such as hypertension, anaemia and mineral metabolism management. Although the results of these studies have been encouraging, demonstrating the effectiveness of audit, overall the present evidence is not clearly in favour of clinical audit. These findings call attention to the need to further studies to validate this methodology in different operating scenarios. This review examines the principle of clinical audit, focusing on experiences performed in nephrology settings.

Bioanalysis of antibody-drug conjugates: American Association of Pharmaceutical Scientists Antibody-Drug Conjugate Working Group position paper.

PubMed

Gorovits, Boris; Alley, Stephen C; Bilic, Sanela; Booth, Brian; Kaur, Surinder; Oldfield, Phillip; Purushothama, Shobha; Rao, Chetana; Shord, Stacy; Siguenza, Patricia

2013-05-01

Antibody-drug conjugates (ADCs) typically consist of a cytotoxic drug covalently bound to an antibody by a linker. These conjugates have the potential to substantially improve efficacy and reduce toxicity compared with cytotoxic small-molecule drugs. Since ADCs are generally complex heterogeneous mixtures of multiple species, these novel therapeutic products present unique bioanalytical challenges. The growing number of ADCs being developed across the industry suggests the need for alignment of the bioanalytical methods or approaches used to assess the multiple species and facilitate consistent interpretation of the bioanalytical data. With limited clinical data, the current strategies that can be used to provide insight into the relationship between the multiple species and the observed clinical safety and efficacy are still evolving. Considerations of the bioanalytical strategies for ADCs based on the current industry practices that take into account the complexity and heterogeneity of ADCs are discussed.

Mechanisms on spasmolytic and anti-inflammatory effects of a herbal medicinal product consisting of myrrh, chamomile flower, and coffee charcoal.

PubMed

Vissiennon, Cica; Goos, Karl-Heinz; Arnhold, Jürgen; Nieber, Karen

2017-05-01

Inflammatory bowel disease or irritable bowel syndrome are chronic gastrointestinal disorders which are associated with a lifelong therapeutic need. The disease results in physical, psychological, and social problems with an impact on partnership, sexuality, education, and career. Thus, the number of patients and health care professionals relying on traditional and complementary medicines and especially phytotherapy for the treatment of these chronic conditions is increasing over recent years. One traditional herbal medicinal product consisting of chamomile flower, myrrh, and coffee charcoal has been widely used in clinical practice within this indication area. Long-term experience and an increasing understanding of the pharmacological mechanisms substantiate its application and clinical effectiveness. Mainly the spasmolytic and anti-inflammatory effects provide a rationale for its therapeutic application. In addition, synergistic effects between the herbal components contribute to the overall effect of this medication.

Randomized clinical trials in implant therapy: relationships among methodological, statistical, clinical, paratextual features and number of citations.

PubMed

Nieri, Michele; Clauser, Carlo; Franceschi, Debora; Pagliaro, Umberto; Saletta, Daniele; Pini-Prato, Giovanpaolo

2007-08-01

The aim of the present study was to investigate the relationships among reported methodological, statistical, clinical and paratextual variables of randomized clinical trials (RCTs) in implant therapy, and their influence on subsequent research. The material consisted of the RCTs in implant therapy published through the end of the year 2000. Methodological, statistical, clinical and paratextual features of the articles were assessed and recorded. The perceived clinical relevance was subjectively evaluated by an experienced clinician on anonymous abstracts. The impact on research was measured by the number of citations found in the Science Citation Index. A new statistical technique (Structural learning of Bayesian Networks) was used to assess the relationships among the considered variables. Descriptive statistics revealed that the reported methodology and statistics of RCTs in implant therapy were defective. Follow-up of the studies was generally short. The perceived clinical relevance appeared to be associated with the objectives of the studies and with the number of published images in the original articles. The impact on research was related to the nationality of the involved institutions and to the number of published images. RCTs in implant therapy (until 2000) show important methodological and statistical flaws and may not be appropriate for guiding clinicians in their practice. The methodological and statistical quality of the studies did not appear to affect their impact on practice and research. Bayesian Networks suggest new and unexpected relationships among the methodological, statistical, clinical and paratextual features of RCTs.

Systematic collection of patient reported outcome research data: A checklist for clinical research professionals.

PubMed

Wehrlen, Leslie; Krumlauf, Mike; Ness, Elizabeth; Maloof, Damiana; Bevans, Margaret

2016-05-01

Understanding the human experience is no longer an outcome explored strictly by social and behavioral researchers. Increasingly, biomedical researchers are also including patient reported outcomes (PROs) in their clinical research studies not only due to calls for increased patient engagement in research but also healthcare. Collecting PROs in clinical research studies offers a lens into the patient's unique perspective providing important information to industry sponsors and the FDA. Approximately 30% of trials include PROs as primary or secondary endpoints and a quarter of FDA new drug, device and biologic applications include PRO data to support labeling claims. In this paper PRO, represents any information obtained directly from the patient or their proxy, without interpretation by another individual to ascertain their health, evaluate symptoms or conditions and extends the reference of PRO, as defined by the FDA, to include other sources such as patient diaries. Consumers and clinicians consistently report that PRO data are valued, and can aide when deciding between treatment options; therefore an integral part of clinical research. However, little guidance exists for clinical research professionals (CRPs) responsible for collecting PRO data on the best practices to ensure quality data collection so that an accurate assessment of the patient's view is collected. Therefore the purpose of this work was to develop and validate a checklist to guide quality collection of PRO data. The checklist synthesizes best practices from published literature and expert opinions addressing practical and methodological challenges CRPs often encounter when collecting PRO data in research settings. Published by Elsevier Inc.

Tobacco dependence counseling in a randomized multisite clinical trial

PubMed Central

Croghan, Ivana T.; Trautman, Judith A.; Winhusen, Theresa; Ebbert, Jon O.; Kropp, Frankie; Schroeder, Darrell R.; Hurt, Richard D.

2012-01-01

Pharmacotherapy trials for treating tobacco dependence would benefit from behavioral interventions providing treatment consistent with clinical practice guidelines but not directing participants to treatments not evaluated in the trial. The Smoke Free and Living It© behavioral intervention manual includes participant and interventionist guides and is designed to provide both practical counseling and intra-treatment support. We utilized this intervention manual in a multicenter, randomized clinical trial of smokers with attention deficit hyperactivity disorder. In this study, we evaluated how the interventional manual performed in a “train-the-trainer” model requiring uniform counseling across 6 sites and 15 interventionists. We analyzed the skill-adherence of the interventionists and the intervention-adherence of the participants. The 255 randomized participants completed 9.3 ± 2.8 sessions (mean ± SD), with 157 participants (61.6%) completing all 11 of the sessions and 221 (86.7%) completing at least 6 of the 11 sessions. Of the 163 sessions for which the study interventionists were evaluated, 156 (95.7%) were rated as adherent to protocol and “meeting expectations” on at least 6 of 7 established criteria, illustrating that fidelity can be maintained with minimal supervision. The self-help and interventionists guides of the Smoke Free and Living It manual can thus be used to provide behavioral intervention with a high rate of adherence by both the interventionists and the participants. This manual meets the requirements of the United States Public Health Service Clinical Practice Guideline, can be adapted to specific research protocols, and provides a useful option for behavioral intervention during clinical trials for smoking cessation. PMID:22406192

Tips for Teachers of Evidence-based Medicine: Clinical Prediction Rules (CPRs) and Estimating Pretest Probability

PubMed Central

McGinn, Thomas; Jervis, Ramiro; Wisnivesky, Juan; Keitz, Sheri

2008-01-01

Background Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians’ diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives. Educational Objectives In this article, we present 3 teaching tips aimed at helping clinical learners use clinical prediction rules and to more accurately assess pretest probability in every day practice. The first tip is designed to demonstrate variability in physician estimation of pretest probability. The second tip demonstrates how the estimate of pretest probability influences the interpretation of diagnostic tests and patient management. The third tip exposes learners to various examples and different types of Clinical Prediction Rules (CPR) and how to apply them in practice. Pilot Testing We field tested all 3 tips with 16 learners, a mix of interns and senior residents. Teacher preparatory time was approximately 2 hours. The field test utilized a board and a data projector; 3 handouts were prepared. The tips were felt to be clear and the educational objectives reached. Potential teaching pitfalls were identified. Conclusion Teaching with these tips will help physicians appreciate the importance of applying evidence to their every day decisions. In 2 or 3 short teaching sessions, clinicians can also become familiar with the use of CPRs in applying evidence consistently in everyday practice. PMID:18491194

Tobacco dependence counseling in a randomized multisite clinical trial.

PubMed

Croghan, Ivana T; Trautman, Judith A; Winhusen, Theresa; Ebbert, Jon O; Kropp, Frankie B; Schroeder, Darrell R; Hurt, Richard D

2012-07-01

Pharmacotherapy trials for treating tobacco dependence would benefit from behavioral interventions providing treatment consistent with clinical practice guidelines but not directing participants to treatments not evaluated in the trial. The Smoke Free and Living It© behavioral intervention manual includes participant and interventionist guides and is designed to provide both practical counseling and intra-treatment support. We utilized this intervention manual in a multicenter, randomized clinical trial of smokers with attention deficit hyperactivity disorder. In this study, we evaluated how the interventional manual performed in a "train-the-trainer" model requiring uniform counseling across 6 sites and 15 interventionists. We analyzed the skill-adherence of the interventionists and the intervention-adherence of the participants. The 255 randomized participants completed 9.3±2.8 sessions (mean±SD), with 157 participants (61.6%) completing all 11 of the sessions and 221 (86.7%) completing at least 6 of the 11 sessions. Of the 163 sessions for which the study interventionists were evaluated, 156 (95.7%) were rated as adherent to protocol and "meeting expectations" on at least 6 of 7 established criteria, illustrating that fidelity can be maintained with minimal supervision. The self-help and interventionists guides of the Smoke Free and Living It manual can thus be used to provide behavioral intervention with a high rate of adherence by both the interventionists and the participants. This manual meets the requirements of the United States Public Health Service Clinical Practice Guideline, can be adapted to specific research protocols, and provides a useful option for behavioral intervention during clinical trials for smoking cessation. Copyright © 2012 Elsevier Inc. All rights reserved.

Reported use of evidence in clinical practice: a survey of rehabilitation practices in Norway.

PubMed

Moore, Jennifer L; Friis, Svein; Graham, Ian D; Gundersen, Elisabeth Troøyen; Nordvik, Jan E

2018-05-25

The South Eastern Health Region in Norway serves approximately 2.8 million people, which is more than half of Norway's population. Physical medicine and rehabilitation services are provided by 9 public hospital trusts and 30 private rehabilitation facilities. The purposes of this study were to conduct a psychometric analysis of the EBP Implementation Scale (EBPIS) and describe rehabilitation clinicians' self-reported 1) use of evidence-based practices (EBPs), 2) use of EBPs across hospitals, and 3) determine factors associated with use of EBPs in the South Eastern Health Region in Norway. A cross-sectional study using an online survey was conducted with public hospitals and private rehabilitation centers. The survey, which was distributed throughout the region, included the EBPIS, 8 questions related to EBP in the health region, and demographics. Response frequencies were calculated and described. Internal consistency and factor structure of the EBPIS and its subscales were determined. Associations and differences in groups with similar demographics, EBPIS scores, and use of EBPs were identified. A total of 316 individuals completed the survey, including allied health clinicians, nurses, psychologists, social workers, and physicians. The EBPIS mean score was 30/72. A factor analysis identified that the EBPIS can be divided into 3 subscales: literature search and critical appraisal (α = .80), knowledge sharing (α = .83), and practice evaluation (α = .74). EBP activities reported were primarily related to literature searches, critical appraisal, and discussing evidence. Approximately 65 and 75% of respondents agreed that the same OMs and evidence based interventions were used within the local clinic respectively. Fewer agreed that the same OMs (13%) and evidence-based interventions (39%) are used regionally. The EBPIS and its subscales demonstrated excellent internal consistency. Practice variability exists in rehabilitation throughout Southeastern Norway. An increased emphasis on use of EBP throughout the region is needed.

Improving Chronic Diseases Management Through the Development of an Evidence-Based Resource.

PubMed

Khalil, Hanan; Chambers, Helen; Munn, Zachary; Porritt, Kylie

2015-06-01

There is a large gap between evidence and practice within health care, particularly within the field of chronic disease. To reduce this gap and improve the management of chronic disease, a collaborative partnership between two schools within a large university and two industry partners (a large regional rural hospital and a rural community health center) in rural Victoria, Australia, was developed. The aim of the collaboration was to promote the development of translation science and the implementation of evidence-based health care in chronic disease with a specific focus on developing evidence-based resources that are easily accessed by clinicians. A working group consisting of members of the collaborating organizations and an internationally renowned expert reference group was formed. The group acted as a steering committee and was tasked with developing a taxonomy of the resources. In addition, a peer review process of all resources was established. A corresponding reference group consisting of researchers and clinicians who are clinical experts in various fields was involved in the review process. The resources developed by the group include evidence summaries and recommended practices made available on a web-based database, which can be accessed via subscription by clinicians and researchers worldwide. As of mid-2014, there were 109 new evidence summaries and 25 recommended practices detailing the best available evidence on topics related to chronic disease management including asthma, diabetes, heart failure, dementia, and others. Training sessions and a newsletter were developed for clinicians within the node to enable them to use the content effectively. This paper describes the processes involved in the successful development of the collaborative partnership and its evolution into producing a valuable resource for the translation of evidence into practice in the areas of chronic disease management. The resource developed is being used by clinicians to inform practice and support their clinical decision making. © 2015 Sigma Theta Tau International.

Prevention of venous thromboembolism in long term care: results of a multicenter educational intervention using clinical practice guidelines: part 2 of 2 (an AMDA Foundation project).

PubMed

Dharmarajan, T S; Nanda, Aman; Agarwal, Bikash; Agnihotri, Parag; Doxsie, G L; Gokula, Murthy; Javaheri, Ashkan; Kanagala, M; Lebelt, Anna S; Madireddy, Prasuna; Mahapatra, Sourya; Murakonda, P; Muthavarapu, S Ram Rao; Patel, Mennakshi; Patterson, Christopher; Soch, Kathleen; Troncales, Anna; Yaokim, Kamal; Kroft, Robin; Norkus, Edward P

2012-03-01

Implementation of prophylaxis for venous thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) is variably adopted in long term care facilities (LTCF). Current guidelines recommend venous thromboembolism prophylaxis (VTE-P) following risk assessment, individualized to patient status. In LTCF, differing comorbidity, life-expectancy, ethical, and quality-of-life issues may warrant a unique approach. This article examines VTE-P practices in LTCF before and after educational intervention to bring practice patterns consistent with CPGs. Phase 1 (preceding article in this issue) identified current practice to assess risk and implement VTE-P (17 geographically diverse LTCFs, 3260 total beds). Phase 2 (educational intervention using CPGs) and Phase 3 (outcomes) reexamined VTE-P at the same 17 centers. The frequency of indications for VTE-P and contraindications to anticoagulation were similar during Phases 1 and 3 (all P > .05). In Phase 3, use of aspirin alone decreased more than 50% (P < .0005), whereas use of compression devices increased (P < .0005). Regression models predicted no relationship between any indication or contraindication and VTE-P in Phase 1 (all P > .05) but identified significant relationships between indication and contraindications and VTE-P in Phase 3 (P = .022 to P < .0005), suggesting adequate understanding of current CPGs following education as the basis for improved VTE-P. The study confirms the presence of significant comorbidity in LTC residents, many with indications for VTE-P, some with contraindications for anticoagulation. Following educational intervention, more residents received VTE-P, influenced by risk-benefit ratio favoring treatment. These findings suggest that even a modest educational intervention significantly improves provider knowledge pertinent to risk assessment consistent with CPG and more appropriate VTE-P. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Infection prevention and control in nursing homes: a qualitative study of decision-making regarding isolation-based practices.

PubMed

Cohen, Catherine Crawford; Pogorzelska-Maziarz, Monika; Herzig, Carolyn T A; Carter, Eileen J; Bjarnadottir, Ragnhildur; Semeraro, Patricia; Travers, Jasmine L; Stone, Patricia W

2015-10-01

Isolation-based practices in nursing homes (NHs) differ from those in acute care. NHs must promote quality of life while preventing infection transmission. Practices used in NHs to reconcile these goals of care have not been characterised. To explore decision-making in isolation-based infection prevention and control practices in NHs. A qualitative study was conducted with staff (eg, staff nurses, infection prevention directors and directors of nursing) employed in purposefully sampled US NHs. Semistructured, role-specific interview guides were developed and interviews were digitally recorded, transcribed verbatim and analysed using directed content analysis. The research team discussed emerging themes in weekly meetings to confirm consensus. We inferred from 73 interviews in 10 NHs that there was variation between NHs in practices regarding who was isolated, when isolation-based practices took place, how they were implemented, and how they were tailored for each resident. Interviewees' decision-making depended on staff perceptions of acceptable transmission risk and resident quality of life. NH resources also influenced decision-making, including availability of private rooms, extent to which staff can devote time to isolation-based practices and communication tools. A lack of understanding of key infection prevention and control concepts was also revealed. Current clinical guidelines are not specific enough to ensure consistent practice that meets care goals and resource constraints in NHs. However, new epidemiological research regarding effectiveness of varying isolation practices in this setting is needed to inform clinical practice. Further, additional infection prevention and control education for NH staff may be required. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Internal quality control: best practice.

PubMed

Kinns, Helen; Pitkin, Sarah; Housley, David; Freedman, Danielle B

2013-12-01

There is a wide variation in laboratory practice with regard to implementation and review of internal quality control (IQC). A poor approach can lead to a spectrum of scenarios from validation of incorrect patient results to over investigation of falsely rejected analytical runs. This article will provide a practical approach for the routine clinical biochemistry laboratory to introduce an efficient quality control system that will optimise error detection and reduce the rate of false rejection. Each stage of the IQC system is considered, from selection of IQC material to selection of IQC rules, and finally the appropriate action to follow when a rejection signal has been obtained. The main objective of IQC is to ensure day-to-day consistency of an analytical process and thus help to determine whether patient results are reliable enough to be released. The required quality and assay performance varies between analytes as does the definition of a clinically significant error. Unfortunately many laboratories currently decide what is clinically significant at the troubleshooting stage. Assay-specific IQC systems will reduce the number of inappropriate sample-run rejections compared with the blanket use of one IQC rule. In practice, only three or four different IQC rules are required for the whole of the routine biochemistry repertoire as assays are assigned into groups based on performance. The tools to categorise performance and assign IQC rules based on that performance are presented. Although significant investment of time and education is required prior to implementation, laboratories have shown that such systems achieve considerable reductions in cost and labour.

[Guidelines for the management of hypertension].

PubMed

Prieto-Díaz, Miguel Ángel

2014-09-01

In the last year, several scientific societies have published guidelines for the management of arterial hypertension. In Spain, two clinical practice guidelines have had a strong impact and have been closely followed in the last few years: the first is the Guideline of the National Heart, Lung and Blood Institute, although their last report (JNC 7) was published in 2003; the second is the clinical practice guideline for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), whose latest version was published in 2007, although an update was published in 2009. A new ESC/ESH document, published in 2013, adopts a mainly educational stance, closely rooted in clinical practice. Many of the recommendations maintain the same criteria as previous guidelines. However, the new publication shows greater rigor and contains major contributions such as specification of the level of evidence and grade of recommendation for each recommendation, which was lacking in the previous guidelines of these societies. The document is both practical and easy to consult, consisting of 17 tables, 5 figures and 18 blocks of recommendations. The JNC 8 report, however, has a single objective: to respond to three questions that are considered a priority and which refer exclusively to drug therapy. Nine recommendations are made relating to these three questions. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Medicina Rural y Generalista (SEMERGEN). All rights reserved.

Assessment of three frequently used blood glucose monitoring devices in clinical routine.

PubMed

Zueger, Thomas; Schuler, Vanessa; Stettler, Christoph; Diem, Peter; Christ, Emanuel R

2012-07-12

Self-monitoring of blood glucose plays an important role in the management of diabetes and has been shown to improve metabolic control. The use of blood glucose meters in clinical practice requires sufficient reliability to allow adequate treatment. Direct comparison of different blood glucose meters in clinical practice, independent of the manufactures is scarce. We, therefore, aimed to evaluate three frequently used blood glucose meters in daily clinical practice. Capillary blood glucose was measured simultaneous using the following glucose meters: Contour® (Bayer Diabetes Care, Zürich, Switzerland), Accu-Chek® aviva (Roche Diagnostics, Rotkreuz, Switzerland), Free-Style® lite (Abbott Diabetes Care, Baar, Switzerland). The reference method consisted of the HemoCue® Glucose 201+ System (HemoCue® AB, Ängelholm, Sweden) with plasma conversion. The devices were assessed by comparison of the Mean Absolute Relative Differences (MARD), the Clarke Error Grid Analysis (EGA) and the compliance with the International Organization of Standardization criteria (ISO 15197:2003). Capillary blood samples were obtained from 150 patients. MARD was 10.1 ± 0.65%, 7.0 ± 0.62% and 7.8 ± 0.48% for Contour®, Accu-Chek® and Free-Style®, respectively. EGA showed 99.3% (Contour®), 98.7% (Accu-Chek®) and 100% (Free-Style®) of all measurements in zone A and B (clinically acceptable). The ISO criteria were fulfilled by Accu-Chek® (95.3%) and Free-Style® (96%), but not by Contour® (92%). In the present study the three glucose meters provided good agreement with the reference and reliable results in daily clinical routine. Overall, the Free-Style® and Accu-Chek® device slightly outperformed the Contour® device.

Clinical utility of bone turnover markers in the management of common metabolic bone diseases in adults.

PubMed

Glendenning, Paul; Chubb, S A Paul; Vasikaran, Samuel

2018-06-01

Bone turnover marker (BTMs) concentrations in blood and urine reflect bone-remodelling activity, and may be useful adjuncts in the diagnosis and management of metabolic bone diseases. Newer biomarkers, mainly bone regulatory proteins, are currently being investigated to elucidate their role in bone metabolism and disease and may in future be useful in clinical diagnosis and management of metabolic bone disease. BTM concentrations increase around menopause in women, and at a population level the degree of increase in BTMs reflect bone loss. However, lack of adequate data precludes their use in individual patients for fracture risk assessment in clinical practice. The rapid and large changes in BTMs following anti-resorptive and anabolic therapies for osteoporosis treatment indicate they may be useful for monitoring therapy in clinical practice. The offset of drug effect on BTMs could be helpful for adjudicating the duration of bisphosphonate drug holidays. BTMs may offer useful additional data in skeletal diseases that are typically characterised by increased bone remodelling: chronic kidney disease (CKD), primary hyperparathyroidism (PHPT) and Paget's disease. In CKD, bone specific alkaline phosphatase (bAP) is currently endorsed for use for the assessment of mineral bone disease. The role of BTMsin predicting the bone mineral density response to successful parathyroidectomy in PHPT shows some utility but the data are not consistent and studies are limited in size and/or duration. In Paget's disease of bone, BTMs are used to confirm diagnosis, evaluate extent of disease or degree of activity and for monitoring the response to bisphosphonate treatment. Whilst BTMs are currently used in specific clinical practice instances when investigating or managing metabolic bone disease, further data are needed to consolidate their clinical use where evidence of utility is limited. Copyright © 2018 Elsevier B.V. All rights reserved.

Developing a Peer Mentorship Program to Increase Competence in Clinical Supervision in Clinical Psychology Doctoral Training Programs.

PubMed

Foxwell, Aleksandra A; Kennard, Beth D; Rodgers, Cynthia; Wolfe, Kristin L; Cassedy, Hannah F; Thomas, Anna

2017-12-01

Supervision has recently been recognized as a core competency for clinical psychologists. This recognition of supervision as a distinct competency has evolved in the context of an overall focus on competency-based education and training in health service psychology, and has recently gained momentum. Few clinical psychology doctoral programs offer formal training experiences in providing supervision. A pilot peer mentorship program (PMP) where graduate students were trained in the knowledge and practice of supervision was developed. The focus of the PMP was to develop basic supervision skills in advanced clinical psychology graduate students, as well as to train junior doctoral students in fundamental clinical and practical skills. Advanced doctoral students were matched to junior doctoral students to gain experience in and increase knowledge base in best practices of supervision skills. The 9-month program consisted of monthly mentorship meetings and three training sessions. The results suggested that mentors reported a 30% or more shift from the category of not competent to needs improvement or competent, in the following supervision competencies: theories of supervision, improved skill in supervision modalities, acquired knowledge in supervision, and supervision experience. Furthermore, 50% of the mentors reported that they were not competent in supervision experience at baseline and only 10% reported that they were not competent at the end of the program. Satisfaction data suggested that satisfaction with the program was high, with 75% of participants indicating increased knowledge base in supervision, and 90% indicating that it was a positive addition to their training program. This program was feasible and acceptable and appears to have had a positive impact on the graduate students who participated. Students reported both high satisfaction with the program as well as an increase in knowledge base and experience in supervision skills.

An educational approach to improve outcomes in acute kidney injury (AKI): report of a quality improvement project.

PubMed

Xu, Gang; Baines, Richard; Westacott, Rachel; Selby, Nick; Carr, Susan

2014-03-20

To assess the impact of a quality improvement project that used a multifaceted educational intervention on how to improve clinician's knowledge, confidence and awareness of acute kidney injury (AKI). 2 large acute teaching hospitals in England, serving a combined population of over 1.5 million people. All secondary care clinicians working in the clinical areas were targeted, with a specific focus on clinicians working in acute admission areas. A multifaceted educational intervention consisting of traditional didactic lectures, case-based teaching in small groups and an interactive web-based learning resource. We assessed clinicians' knowledge of AKI and their self-reported clinical behaviour using an interactive questionnaire before and after the educational intervention. Secondary outcome measures included clinical audit of patient notes before and after the intervention. 26% of clinicians reported that they were aware of local AKI guidelines in the preintervention questionnaire compared to 64% in the follow-up questionnaire (χ²=60.2, p<0.001). There was an improvement in the number of clinicians reporting satisfactory practice when diagnosing AKI, 50% vs 68% (χ²=12.1, p<0.001) and investigating patients with AKI, 48% vs 64% (χ²=9.5, p=0.002). Clinical audit makers showed a trend towards better clinical practice. This quality improvement project utilising a multifaceted educational intervention improved awareness of AKI as demonstrated by changes in the clinician's self-reported management of patients with AKI. Elements of the project have been sustained beyond the project period, and demonstrate the power of quality improvement projects to help initiate changes in practice. Our findings are limited by confounding factors and highlight the need to carry out formal randomised studies to determine the impact of educational initiatives in the clinical setting.

Pitfalls With the New American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy.

PubMed

Pauli, Jaimey M; Repke, John T

2017-03-01

The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy was created to evaluate the existing literature, develop practice guidelines, and identify areas for future research focus. Several issues were identified that may not have been initially obvious during the process of developing this document, including limited practical use, a lack of high quality literature, conflicting recommendations, a potential for high resource utilization, need for continually updated information, and little headway in research that is clinically useful. The purpose of this review was to make suggestions to improving these guidelines' overall usefulness and consistency for the busy clinician.

Swiss family physicians' perceptions and attitudes towards knowledge translation practices.

PubMed

Bengough, Theresa; Bovet, Emilie; Bécherraz, Camille; Schlegel, Susanne; Burnand, Bernard; Pidoux, Vincent

2015-12-11

Several studies have been performed to understand the way family physicians apply knowledge from medical research in practice. However, very little is known concerning family physicians in Switzerland. In an environment in which information constantly accumulates, it is crucial to identify the major sources of scientific information that are used by family physicians to keep their medical knowledge up to date and barriers to use these sources. Our main objective was to examine medical knowledge translation (KT) practices of Swiss family physicians. The population consisted of French- and German-speaking private practice physicians specialised in family medicine. We conducted four interviews and three focus groups (n = 25). The interview guides of the semi-structured interviews and focus groups focused on (a) ways and means used by physicians to keep updated with information relevant to clinical practice; (b) how they consider their role in translating knowledge into practice; (c) potential barriers to KT; (d) solutions proposed by physicians for effective KT. Family physicians find themselves rather ambivalent about the translation of knowledge based on scientific literature, but generally express much interest in KT. They often feel overwhelmed by "information floods" and perceive clinical practice guidelines and other supports to be of limited usefulness for their practice. They often combine various formal and informal information sources to keep their knowledge up to date. Swiss family physicians report considering themselves as artisans, caring for patients with complex needs. Improved performance of KT initiatives in family medicine should be tailored to actual needs and based on high quality evidence-based sources.

A potential non-invasive approach to evaluating blastocyst quality using biodynamic imaging

NASA Astrophysics Data System (ADS)

Li, Zhe; Ehmke, Natalie; Machaty, Zoltan; Nolte, David

2018-02-01

Biodynamic imaging (BDI) is capable of capturing the intracellular dynamics of blastocysts within a relatively short time. Spectroscopic signatures of embryos in the 0.01 Hz - 1 Hz range display responses to external factors before morphology changes take place. Viability evaluation is consistent with results from other non-invasive methods. Biodynamic imaging is a potential tool for selecting high quality embryos in clinical IVF practices.

An educational game for teaching clinical practice guidelines to Internal Medicine residents: development, feasibility and acceptability

PubMed Central

Akl, Elie A; Mustafa, Reem; Slomka, Thomas; Alawneh, Alia; Vedavalli, Abhishek; Schünemann, Holger J

2008-01-01

Background Adherence to Clinical Practice Guidelines (CPGs) remains suboptimal among internal medicine trainees. Educational games are of growing interest and have the potential to improve adherence to CPGs. The objectives of this study were to develop an educational game to teach CPGs in Internal Medicine residency programs and to evaluate its feasibility and acceptability. Methods We developed the Guide-O-Game© in the format of a TV game show with questions based on recommendations of CPGs. The development of the Guide-O-Game© consisted of the creation of a multimedia interactive tool, the development of recommendation-based questions, and the definition of the game's rules. We evaluated its feasibility through pilot testing and its acceptability through a qualitative process. Results The multimedia interactive tool uses a Macromedia Flash web application and consists of a manager interface and a user interface. The user interface allows the choice of two game styles. We created so far 16 sets of questions relating to 9 CPGs. The pilot testing proved that the game was feasible. The qualitative evaluation showed that residents considered the game to be acceptable. Conclusion We developed an educational game to teach CPGs to Internal Medicine residents that is both feasible and acceptable. Future work should evaluate its impact on educational outcomes. PMID:19017400

Evaluation of Team-Based Care in an Urban Free Clinic Setting.

PubMed

Iddins, Brenda W; Frank, Jennifer Sandson; Kannar, Pegah; Curry, William A; Mullins, Melissa; Hites, Lisle; Selleck, Cynthia

2015-01-01

This article reports the experiences of a school of nursing, academic health center, and community-based organization working via an interprofessional collaborative practice model to meet the mutual goal of serving the health care needs of an indigent, largely minority population in Birmingham, Alabama. The population suffers disproportionately from chronic health problems including diabetes, obesity, cardiovascular disease, asthma, and mental health disorders. The program emphasizes diabetes management because the academic health center recognized the need for transitional and primary care, including mental health services, for the increasing numbers of uninsured patients with diabetes and its comorbidities. Half of the clinicians involved in this project had no prior experience with interprofessional collaborative practice, and there was confusion regarding the roles of team members from the partnering institutions. Activities involving care coordination consistently received low scores on weekly rating scales leading to the creation of positions for a nurse care manager and pharmaceutical patient assistance program coordinator. Conversely, shared decision making and cooperation ratings were consistently high. Evaluation identified the need for reliable, accessible data and data analysis to target clinically effective interventions and care coordination and to assess cost effectiveness. The strengths, challenges, lessons learned, and next steps required for sustainability of this alignment are discussed.

The young adult Strengths and Difficulties Questionnaire (SDQ) in routine clinical practice.

PubMed

Brann, Peter; Lethbridge, Melissa J; Mildred, Helen

2018-06-01

Expansion of the youth mental health sector has exposed a need for an outcome measure for young adults accessing services. The Strengths and Difficulties Questionnaire (SDQ) is a widely used consumer and carer outcome measure for children and adolescents. The aim of this study was to evaluate the psychometric properties of a young adult SDQ. The young adult SDQ was introduced for routine clinical practice at Eastern Health Child and Youth Mental Health Service (EH-CYMHS), complementing the well-established adolescent and child versions. Data for adolescents (aged 12-17) and young adults (aged 18-25) where both self-report and parent SDQs had been completed at entry point to the service were extracted from a two-year period. Overall, paired cases involved 532 adolescents and 125 young adults. Across both self-report and parent SDQs, a similar pattern of results was found between adolescents and young adults on mean scores, inter-scale correlations, internal consistency, and inter-rater agreement. The findings of the current study support the use of the young adult SDQ in public mental health as an instrument whose psychometric properties, to date, appear consistent with those of the adolescent version. Further investigation is warranted. Copyright © 2018 Elsevier B.V. All rights reserved.

Tuberculosis infection control measures in health care facilities offering tb services in Ikeja local government area, Lagos, South West, Nigeria.

PubMed

Kuyinu, Y A; Mohammed, A S; Adeyeye, O O; Odugbemi, B A; Goodman, O O; Odusanya, O O

2016-03-15

Tuberculosis infection among health care workers is capable of worsening the existing health human resource problems of low--and middle-income countries. Tuberculosis infection control is often weakly implemented in these parts of the world therefore, understanding the reasons for poor implementation of tuberculosis infection control guidelines are important. This study was aimed at assessing tuberculosis infection control practices and barriers to its implementation in Ikeja, Nigeria. A cross-sectional study in 20 tuberculosis care facilities (16 public and 4 private) in Ikeja, Lagos was conducted. The study included a facility survey to assess the availability of tuberculosis infection control guidelines, the adequacy of facilities to prevent transmission of tuberculosis and observations of practices to assess the implementation of tuberculosis infection control guidelines. Four focus group discussions were carried out to highlight HCWs' perceptions on tuberculosis infection control guidelines and barriers to its implementation. The observational study showed that none of the clinics had a tuberculosis infection control plan. No clinic was consistently screening patients for cough. Twelve facilities (60%) consistently provided masks to patients who were coughing. Ventilation in the waiting areas was assessed to be adequate in 60% of the clinics while four clinics (20%) possessed N-95 respirators. Findings from the focus group discussions showed weak managerial support, poor funding, under-staffing, lack of space and not wanting to be seen as stigmatizing against tuberculosis patients as barriers that hindered the implementation of TB infection control measures. Tuberculosis infection control measures were not adequately implemented in health facilities in Ikeja, Nigeria. A multi-pronged approach is required to address the identified barriers to the implementation of tuberculosis infection control guidelines.

Representation primitives, process models and patient data in computer-interpretable clinical practice guidelines: a literature review of guideline representation models.

PubMed

Wang, Dongwen; Peleg, Mor; Tu, Samson W; Boxwala, Aziz A; Greenes, Robert A; Patel, Vimla L; Shortliffe, Edward H

2002-12-18

Representation of clinical practice guidelines in a computer-interpretable format is a critical issue for guideline development, implementation, and evaluation. We studied 11 types of guideline representation models that can be used to encode guidelines in computer-interpretable formats. We have consistently found in all reviewed models that primitives for representation of actions and decisions are necessary components of a guideline representation model. Patient states and execution states are important concepts that closely relate to each other. Scheduling constraints on representation primitives can be modeled as sequences, concurrences, alternatives, and loops in a guideline's application process. Nesting of guidelines provides multiple views to a guideline with different granularities. Integration of guidelines with electronic medical records can be facilitated by the introduction of a formal model for patient data. Data collection, decision, patient state, and intervention constitute four basic types of primitives in a guideline's logic flow. Decisions clarify our understanding on a patient's clinical state, while interventions lead to the change from one patient state to another.

COMPUTERIZED TRAINING OF CRYOSURGERY – A SYSTEM APPROACH

PubMed Central

Keelan, Robert; Yamakawa, Soji; Shimada, Kenji; Rabin, Yoed

2014-01-01

The objective of the current study is to provide the foundation for a computerized training platform for cryosurgery. Consistent with clinical practice, the training process targets the correlation of the frozen region contour with the target region shape, using medical imaging and accepted criteria for clinical success. The current study focuses on system design considerations, including a bioheat transfer model, simulation techniques, optimal cryoprobe layout strategy, and a simulation core framework. Two fundamentally different approaches were considered for the development of a cryosurgery simulator, based on a finite-elements (FE) commercial code (ANSYS) and a proprietary finite-difference (FD) code. Results of this study demonstrate that the FE simulator is superior in terms of geometric modeling, while the FD simulator is superior in terms of runtime. Benchmarking results further indicate that the FD simulator is superior in terms of usage of memory resources, pre-processing, parallel processing, and post-processing. It is envisioned that future integration of a human-interface module and clinical data into the proposed computer framework will make computerized training of cryosurgery a practical reality. PMID:23995400

Evaluation of Clinical Reasoning in Basic Emergencies Using a Script Concordance Test

PubMed Central

Charlin, Bernard; Vanpee, Dominique

2010-01-01

Objectives To develop and assess the reliability of a script concordance test (SCT) to evaluate pharmacy students' clinical reasoning when facing basic emergency situations. Design A first aid course was designed that consisted of 8 weekly instructional sessions (4 on internal medicine, including life threatening situations; 2 on pediatrics; and 2 on trauma) in which the instructor presented case studies in a small-group format. In the first and final sessions of the course, a practice SCT was administered to familiarize students with the test format. Assessment A 66-question SCT examination was administered to the 68 third-year pharmacy students enrolled in the first aid course. The students' mean score was 68.5% ± 9.8% and panel members' mean score was 86.5% ± 4.2%. Twenty students were selected randomly to complete a course survey and 85% indicated they were satisfied with using the SCT. Conclusions A first aid SCT was found to be both a practical and reliable testing instrument for assessing the clinical reasoning of pharmacy students in basic emergency situations. PMID:21436943

Supervision for treatment of depression: An experimental study of the role of therapist gender and anxiety.

PubMed

Simpson-Southward, Chloe; Waller, Glenn; Hardy, Gillian E

2016-02-01

Psychological treatments for depression are not always delivered effectively or consistently. Clinical supervision of therapists is often assumed to keep therapy on track, ensuring positive patient outcomes. However, there is a lack of empirical evidence supporting this assumption. This experimental study explored the focus of supervision of depression cases, comparing guidance given to supervisees of different genders and anxiety levels. Participants were clinical supervisors who supervised therapists working with patients with depression. Supervisors indicated their supervision focus for three supervision case vignettes. Supervisee anxiety and gender was varied across vignettes. Supervisors focused calm female supervisees more on therapeutic techniques than state anxious female supervisees. Males were supervised in the same way, regardless of their anxiety. Both male and female supervisors had this pattern of focus. Findings indicate that supervision is influenced by supervisors' own biases towards their supervisees. These factors may cause supervisors to drift from prompting their supervisees to deliver best practice. Suggestions are made for ways to improve the effectiveness of clinical supervision and how these results may inform future research practice. Copyright © 2015 Elsevier Ltd. All rights reserved.

American Telemedicine Association: Telestroke Guidelines

PubMed Central

Berg, Jill; Chong, Brian W.; Gross, Hartmut; Nystrom, Karin; Adeoye, Opeolu; Schwamm, Lee; Wechsler, Lawrence; Whitchurch, Sallie

2017-01-01

Abstract The following telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies. Although telestroke practices may include the more broad utilization of telemedicine across the entire continuum of stroke care, with some even consulting on all neurologic emergencies, this document focuses on the acute phase of stroke, including both pre- and in-hospital encounters for cerebrovascular neurological emergencies. These guidelines describe a network of audiovisual communication and computer systems for delivery of telestroke clinical services and include operations, management, administration, and economic recommendations. These interactive encounters link patients with acute ischemic and hemorrhagic stroke syndromes with acute care facilities with remote and on-site healthcare practitioners providing access to expertise, enhancing clinical practice, and improving quality outcomes and metrics. These guidelines apply specifically to telestroke services and they do not prescribe or recommend overall clinical protocols for stroke patient care. Rather, the focus is on the unique aspects of delivering collaborative bedside and remote care through the telestroke model. PMID:28384077

Early vitrectomy effective for Norrie disease.

PubMed

Walsh, Mark K; Drenser, Kimberly A; Capone, Antonio; Trese, Michael T

2010-04-01

To review our experience with Norrie disease to determine if early vitrectomy abrogates the natural history of this rare disease; namely, bilateral no light perception visual acuity and phthisis bulbi. We retrospectively reviewed the medical records of all patients seen in our tertiary care pediatric retinal clinical practice from 1988 through 2008 with a potential diagnosis of Norrie disease. Inclusion required not only clinical findings consistent with Norrie disease but also genetics and/or a family history consistent with Norrie disease. Medical record review revealed 14 boys with clinically diagnosed Norrie disease and either Norrie disease gene (NDP) mutations noted on genetic testing (13 patients) and/or a clear family history consistent with Norrie disease (4 patients). All 14 boys with definite Norrie disease had vitrectomy with or without lensectomy in at least 1 eye prior to 12 months of age. Of the 14 boys with definite Norrie disease, 7 maintained at least light perception visual acuity in 1 eye and 3 had no light perception visual acuity bilaterally; visual acuity data were not available for 4 patients. Only 2 of 24 (8%) eyes became phthisical. Historically, no treatment has been offered to mitigate the dismal natural history of Norrie disease. We recommend consideration of early vitrectomy in Norrie disease.

A psychometric evaluation of an advanced pharmacy practice experience clinical competency framework.

PubMed

Douglas Ried, L; Doty, Randell E; Nemire, Ruth E

2015-03-25

To assess the psychometric properties of the clinical competency framework known as the System of Universal Clinical Competency Evaluation in the Sunshine State (SUCCESS), including its internal consistency and content, construct, and criterion validity. Sub-competency items within each hypothesized competency pair were subjected to principal components factor analysis to demonstrate convergent and discriminant validity. Varimax rotation was conducted for each competency pair (eg, competency 1 vs competency 2, competency 1 vs competency 3, competency 2 vs competency 3). Internal consistency was evaluated using Cronbach alpha. Of the initial 78 pairings, 44 (56%) demonstrated convergent and discriminant validity. Five pairs of competencies were unidimensional. Of the 34 pairs where at least 1 competency was multidimensional, most (91%) were from competencies 7, 11, and 12, indicating modifications were warranted in those competencies. After reconfiguring the competencies, 76 (94%) of the 81 pairs resulted in 2 factors as required. A unidimensional factor emerged when all 13 of the competencies were entered into a factor analysis. The internal consistency of all of the competencies was satisfactory. Psychometric evaluation shows the SUCCESS framework demonstrates adequate reliability and validity for most competencies. However, it also provides guidance where improvements are needed as part of a continuous quality improvement program.

Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice.

PubMed

Dean, Elizabeth

2009-07-01

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-century health priorities and be aligned with global and regional public health strategies. A proposed focus on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and disability. The 21st-century physical therapist needs to be able to practice such competencies within the context of a culturally diverse society to effect positive health behavior change. The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions. Physical therapists need to impact health globally through public and social health policy as well as one-on-one care. This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical therapists to health and well-being and reduced health risk is consistent with minimizing the substantial social and economic burdens of lifestyle conditions globally.

Influencing Factors on Choosing Psychiatry as a Career: An Exploration in Chinese University Students.

PubMed

Zhong, Jiawei; Zheng, Luna; Chen, Xiaoling; Gao, Qianqian; Zhang, Bingren; Wang, Wei

2016-12-01

There is a consistent need of psychiatric professionals in the world including China, and a consistent challenge to recruit more medical students into the psychiatric careers. We aimed to look for factors which have an impact on career-choosing of psychiatry in Chinese university students. We invited 508 non-medical students (NM), 304 medical students without (MO) and 123 medical students with clinical internship experience (MW), to answer a matrix of 43 questions regarding factors influencing career-choosing of psychiatry. Answers to these questions were analyzed through exploratory and confirmatory factor analyses, once the latent factors were identified and structurally-validated, their mean scores in three groups of students were calculated. Five factors with five items each were identified, namely social status inferiority, career importance, practice reward, career preference, and practice stress. NM scored lower than MO and MW did on Social Status Inferiority; NM group scored higher than MO and MW groups did on Career Importance; MW scored lower than NM and MO did on Practice Reward and on Career Preference; Regarding Practice Stress, NM scored higher than MO did, who then in turn, scored higher than MW did. In addition, Practice Stress was positively correlated with advice of the medical educators; and Social Status Inferiority and Career Preference were positively correlated with the psychiatry teaching of the medical educators. Raising career rewards, improving social status, and reinforcing psychiatric education might help to recruit more medical students to specialize in psychiatry practicing.

Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol

PubMed Central

2010-01-01

Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition. Aims This study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP. Methods The design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12609001022257 (date registered 25th November 2009) PMID:21067614

The full spectrum of ethical issues in dementia care: systematic qualitative review.

PubMed

Strech, Daniel; Mertz, Marcel; Knüppel, Hannes; Neitzke, Gerald; Schmidhuber, Martina

2013-06-01

Integrating ethical issues in dementia-specific training material, clinical guidelines and national strategy plans requires an unbiased awareness of all the relevant ethical issues. To determine systematically and transparently the full spectrum of ethical issues in clinical dementia care. We conducted a systematic review in Medline (restricted to English and German literature published between 2000 and 2011) and Google books (with no restrictions). We applied qualitative text analysis and normative analysis to categorise the spectrum of ethical issues in clinical dementia care. The literature review retrieved 92 references that together mentioned a spectrum of 56 ethical issues in clinical dementia care. The spectrum was structured into seven major categories that consist of first- and second-order categories for ethical issues. The systematically derived spectrum of ethical issues in clinical dementia care presented in this paper can be used as training material for healthcare professionals, students and the public for raising awareness and understanding of the complexity of ethical issues in dementia care. It can also be used to identify ethical issues that should be addressed in dementia-specific training programmes, national strategy plans and clinical practice guidelines. Further research should evaluate whether this new genre of systematic reviews can be applied to the identification of ethical issues in other cognitive and somatic diseases. Also, the practical challenges in addressing ethical issues in training material, guidelines and policies need to be evaluated.

Reporting results from whole-genome and whole-exome sequencing in clinical practice: a proposal for Canada?

PubMed

Zawati, Ma'n H; Parry, David; Thorogood, Adrian; Nguyen, Minh Thu; Boycott, Kym M; Rosenblatt, David; Knoppers, Bartha Maria

2014-01-01

This article proposes recommendations for the use of whole-genome and whole-exome (WGS/WES) sequencing in clinical practice, endorsed by the board of directors of the Canadian College of Medical Geneticists. The publication of statements and recommendations by several international and national organisations on clinical WGS/WES has prompted a need for Canadian-specific guidance. A multi-disciplinary group consisting of lawyers, ethicists, genetic researchers, and clinical geneticists was assembled to review existing guidelines on WGS/WES and identify provisions relevant to the Canadian context. Definitions were provided to orient the recommendations and to minimize confusion with other recommendations. Recommendations include the following: WGS/WES should be used in a judicious and cost-efficient manner; WGS/WES should be used to answer a clinical question; and physicians need to explain to adult patients the nature of the results that could arise, so as to allow them to make informed choices over whether to take the test and which results they wish to receive. Recommendations are also provided for WGS/WES in the pediatric context, and for when results implicate patients' family members. These recommendations are only a proposal to be developed into comprehensive Canadian-based guidelines. They aim to promote discussion about the reporting of WGS/WES results, and to encourage the ethical implementation of these new technologies in the clinical setting.

UK Renal Registry 16th annual report: chapter 12 biochemical variables amongst UK adult dialysis patients in 2012: national and centre-specific analyses.

PubMed

Nicholas, Johann; Shaw, Catriona; Pitcher, David; Dawnay, Anne

2013-01-01

The UK Renal Association clinical practice guidelines include clinical performance measures for biochemical variables in dialysis patients. The UK Renal Registry (UKRR) annually audits dialysis centre performance against these measures as part of its role in promoting continuous quality improvement. Cross sectional performance analyses were undertaken to compare dialysis centre achievement of clinical audit measures for prevalent haemodialysis (HD) and peritoneal dialysis (PD) cohorts in 2012. The biochemical variables studied were phosphate, adjusted calcium, parathyroid hormone, bicarbonate and total cholesterol. In addition, longitudinal analyses were performed (2002-2012) to show changes in achievement of clinical performance measures over time. Fifty-six percent of HD and 61% of PD patients achieved a phosphate within the range recommended by the RA clinical practice guidelines. Seventy-seven percent of HD and 78% of PD patients had adjusted calcium between 2.2-2.5 mmol/L. Fifty-eight percent of HD and 65% of PD patients had parathyroid hormone between 16-72 pmol/L. Fifty-nine percent of HD and 80% of PD patients achieved the audit measure for bicarbonate. There was significant inter-centre variation for all variables studied. The UKRR consistently demonstrates significant inter-centre variation in achievement of biochemical clinical audit measures. Understanding the causes of this variation is an important part of improving the care of dialysis patients in the UK.

Chapter 9 Biochemical variables amongst UK adult dialysis patients in 2010: national and centre-specific analyses.

PubMed

Pruthi, Rishi; Pitcher, David; Dawnay, Anne

2012-01-01

The UK Renal Association clinical practice guidelines include clinical performance measures for biochemical variables in dialysis patients. The UK Renal Registry (UKRR) annually audits dialysis centre performance against these measures as part of its role in promoting continuous quality improvement. Cross sectional performance analyses were undertaken to compare dialysis centre achievement of clinical audit measures for prevalent haemodialysis (HD) and peritoneal dialysis (PD) cohorts in 2010. The biochemical variables studied were phosphate, adjusted calcium, parathyroid hormone, bicarbonate and total cholesterol. In addition longitudinal analyses were performed (2000-2010) to show changes in achievement of clinical performance measures over time. Fifty-six percent of HD and 69% of PD patients achieved a phosphate within the range recommended by the RA clinical practice guidelines. Seventy-five percent of HD and 76% of PD patients had adjusted calcium between 2.2-2.5 mmol/L. Twenty-eight percent of HD and 31% of PD patients had parathyroid hormone between 16- 32 pmol/L. Sixty percent of HD and 80% of PD patients achieved the audit measure for bicarbonate. There was significant inter-centre variation for all variables studied. The UKRR consistently demonstrates significant inter-centre variation in achievement of biochemical clinical audit measures. Understanding the causes of this variation is an important part of improving the care of dialysis patients in the UK. Copyright © 2012 S. Karger AG, Basel.

Normal, Problematic and Compulsive Consumption of Sexually Explicit Media: Clinical Findings using the Compulsive Pornography Consumption (CPC) Scale among Men who have Sex with Men

PubMed Central

Rosser, B. R. Simon; Noor, Syed WB; Iantaffi, Alex

2015-01-01

To assess problematic sexually explicit media (SEM) consumption, and to identify clinically meaningful cut-off points, we examined clinical correlates using the new Compulsive Pornography Consumption (CPC) scale among 1165 participating MSM. Building on scale practices in measuring compulsive sexual behavior, two cut-off points were identified. While most (76-80%) MSM do not report compulsive symptoms, about 16-20% report levels of problematic SEM consumption, including 7% with extreme scores consistent with DSM criteria for compulsive disorders. Demographic, sexual, and HIV risk differences were identified between the three groups. Researchers and clinicians are encouraged to consider using the CPC scale for comprehensive assessment of compulsive sexual behavior. PMID:26167109

Preceptors’ Self-Assessment of Their Ability to Perform the Learning Objectives of an Experiential Program

PubMed Central

2012-01-01

Objective. To evaluate preceptors’ perception of their ability to perform the Structured Practical Experiences in Pharmacy (SPEP) learning objectives through a self-assessment activity. Methods. A self-assessment instrument consisting of 28 learning objectives associated with clinic, community, and hospital pharmacy practice experiences were developed. Preceptors rated their performance ability for each of the learning objectives using a 3-point Likert scale. Results. Of the 116 preceptors, 89 (77%) completed the self-assessment survey instrument. The overall preceptor responses to the items on performance of the 28 SPEP learning objectives ranged from good to excellent. Years of experience, practice experience setting, and involvement as a SPEP or SPEP and PharmD preceptor had no influence on their self-reported capabilities. Conclusion. Most preceptors rated their ability to perform the learning objectives for the structured practical experiences in pharmacy as high. Competency areas requiring further preceptor development were identified. PMID:23193333

Report on the APNA National Psychiatric Mental Health Advanced Practice Registered Nurse Survey.

PubMed

Delaney, Kathleen R; Drew, Barbara L; Rushton, Amy

2018-06-01

Further exploration of the practice roles of psychiatric mental health (PMH) advanced practice registered nurses (APRNs) is warranted. In March of 2016, the American Psychiatric Nurses Association (APNA) conducted a national survey to gather data on the demographics, practice roles, and activities of certified PMH APRNs. The e-mail survey contained 46 questions consistent with minimum data set requirements of the Forum of State Nursing Workforce Centers. The data indicate that PMH APRNs are a clinically active workforce; the majority deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing, and providing psychotherapy. PMH APRNs are delivering care to clients dealing with a range of serious mental illnesses across the life span in a variety of roles. It will be critical to monitor the activities and outcomes of this expanding behavioral health care workforce.

In defense of genuine ignorance: supporting vitality and relevance in graduate curricula.

PubMed

Goren, S; Peter, L; Fischer, S

1992-01-01

Genuine ignorance, defined by John Dewey as curiosity and openmindedness in opposition to repetition of catch phrases and familiar propositions, is nurtured in graduate nursing curricula in which the educational process is congruent with course content. Preparation for advanced practice in the mental health environment of the foreseeable future required abandonment of the familiar medical model in favor of conceptual models consistent with current thinking in psychiatric nursing and exposure to current problems (homelessness, family violence, AIDS) and current problem solving strategies (brief treatment, family preservation). Involvement in practice-based research and operationalizing new perspectives on familiar clinical problems, are suggested as strategies for developing the advanced practitioner. Two of the authors, former graduate students, describe the impact of changed perspectives and research activity on their own practice.

Brazilian version of the Nottingham Sensory Assessment: validity, agreement and reliability.

PubMed

Lima, Daniela H F; Queiroz, Ana P; De Salvo, Geovana; Yoneyama, Simone M; Oberg, Telma D; Lima, Núbia M F V

2010-01-01

To investigate the inter-rater and intra-rater reliability, construct validity and internal consistency of the Brazilian version of the Nottingham Sensory Assessment for Stroke Patients (NSA). The instrument was translated into Portuguese from its original in English by a bilingual translator and was then back-translated into English. Twenty-one hemiparetics were evaluated by two examiners using the NSA and the Fugl-Meyer Assessment (FMA) of physical performance. Significant correlation were found between the FMA and the NSA (r=0.752). The NSA showed excellent internal consistency (0.86), and there were acceptable inter- and intra-rater reliability for all items of the NSA, except temperature. Significant ceiling effects were found for the NSA and the FMA. The Brazilian version of the NSA met the criteria for agreement, internal consistency and concurrent validity. It was quick and easy to apply, and it could be used within clinical practice in neuro-rehabilitation outpatient clinics to assess sensory functions following stroke. The significant ceiling effect for the NSA did not limit its use, given that for the same patients, the FMA also showed ceiling effects.

Final assessment of nursing students in clinical practice: Perspectives of nursing teachers, students and mentors.

PubMed

Helminen, Kristiina; Johnson, Martin; Isoaho, Hannu; Turunen, Hannele; Tossavainen, Kerttu

2017-12-01

To describe the phenomenon of final assessment of the clinical practice of nursing students and to examine whether there were differences in assessments by the students and their teachers and mentors. Final assessment of students in clinical practice during their education has great importance for ensuring that enough high-quality nursing students are trained, as assessment tasks affect what the nursing student learns during the clinical practice. This study used descriptive, cross-sectional design. The population of this study comprised nursing students (n = 276) and their teachers (n = 108) in five universities of applied sciences in Finland as well as mentors (n = 225) who came from five partner hospitals. A questionnaire developed for this study contained questions about background variables as well as structured questions scored on a four-point scale, which also allowed the respondents to provide additional comments. When comparing the results related to nursing teachers' presence in the final assessment situation, it was found that teachers and mentors evaluated this as being carried out more often than nursing students suggested. Nursing students noted that fair and consistent assessment is carried out more often than nursing teachers thought. Mentors and teachers said that honest and direct criteria-based final assessment was carried out more often than nursing students evaluated. Nursing students and mentors need support from educational institutions and from nursing teachers in order to ensure the completion of a relevant assessment process. The findings of this study highlight an awareness of final assessment process. It is desirable to have a common understanding, for example, of how the assessment should be managed and what the assessment criteria are, as this will ensure a good quality process. © 2017 John Wiley & Sons Ltd.

FY1 doctors' ethicolegal challenges in their first year of clinical practice: an interview study.

PubMed

Vivekananda-Schmidt, Pirashanthie; Vernon, Bryan

2014-04-01

There is little evidence of junior trainee perspectives in the design and implementation of medical ethics and law (MEL) curriculum in UK medical schools. To determine the ethical issues the foundation year 1 (FY1) doctors (first year after graduation)  encountered during clinical practice and the skills and knowledge of MEL, which were useful in informing MEL curriculum development. The National Research Ethics Service gave ethical approval. Eighteen one-to-one interviews were conducted in each school with FY1 doctors. Interviews were recorded and transcribed verbatim; a thematic analysis was undertaken with the transcriptions and saturation of themes was achieved. Themes closely overlapped between the two study sites. (1) Knowing my place as an FY1 (this theme consisted of four subthemes: challenging the hierarchy, being honest when the team is titrating the truth, taking consent for unfamiliar procedures and personal safety vs competing considerations); (2) Do not attempt resuscitation)/end-of-life pathway and its implications; (3) 'You have to be there' (contextualising ethics and law teaching through cases or role plays to allow students to explore future work situations); and (4) advanced interpersonal skills competency for ethical clinical practice. The data provide a snapshot of the real challenges faced by MEL FY1 doctors in early clinical practice: they may feel ill-prepared and sometimes unsupported by senior members of the team. The key themes suggest areas for development of undergraduate and postgraduate MEL curricula. We will work to develop our own curriculum accordingly. We intend to further investigate the applicability of our findings to UK medical ethics and law curriculum.

Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult.

PubMed

Mearin, Fermín; Ciriza, Constanza; Mínguez, Miguel; Rey, Enrique; Mascort, Juan José; Peña, Enrique; Cañones, Pedro; Júdez, Javier

2016-06-01

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.

Euro-NOTES Status Paper: from the concept to clinical practice.

PubMed

Fuchs, K H; Meining, A; von Renteln, D; Fernandez-Esparrach, G; Breithaupt, W; Zornig, C; Lacy, A

2013-05-01

The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures. After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed. The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections. NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.

Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative

PubMed Central

Visser, K; Katchamart, W; Loza, E; Martinez-Lopez, J A; Salliot, C; Trudeau, J; Bombardier, C; Carmona, L; van der Heijde, D; Bijlsma, J W J; Boumpas, D T; Canhao, H; Edwards, C J; Hamuryudan, V; Kvien, T K; Leeb, B F; Martín-Mola, E M; Mielants, H; Müller-Ladner, U; Murphy, G; Østergaard, M; Pereira, I A; Ramos-Remus, C; Valentini, G; Zochling, J; Dougados, M

2009-01-01

Objectives: To develop evidence-based recommendations for the use of methotrexate in daily clinical practice in rheumatic disorders. Methods: 751 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2007–8 consisting of three separate rounds of discussions and Delphi votes. Ten clinical questions concerning the use of methotrexate in rheumatic disorders were formulated. A systematic literature search in Medline, Embase, Cochrane Library and 2005–7 American College of Rheumatology/European League Against Rheumatism meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford levels of evidence. Each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed. Results: A total of 16 979 references was identified, of which 304 articles were included in the systematic reviews. Ten multinational key recommendations on the use of methotrexate were formulated. Nine recommendations were specific for rheumatoid arthritis (RA), including the work-up before initiating methotrexate, optimal dosage and route, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy and management in the perioperative period and before/during pregnancy. One recommendation concerned methotrexate as a steroid-sparing agent in other rheumatic diseases. Conclusions: Ten recommendations for the use of methotrexate in daily clinical practice focussed on RA were developed, which are evidence based and supported by a large panel of rheumatologists, enhancing their validity and practical use. PMID:19033291

Early predictors of need for remediation in the Australian general practice training program: a retrospective cohort study.

PubMed

Magin, Parker; Stewart, Rebecca; Turnock, Allison; Tapley, Amanda; Holliday, Elizabeth; Cooling, Nick

2017-10-01

Underperforming trainees requiring remediation may threaten patient safety and are challenging for vocational training programs. Decisions to institute remediation are high-stakes-remediation being resource-intensive and emotionally demanding on trainees. Detection of underperformance requiring remediation is particularly problematic in general (family) practice. We sought to establish early-training assessment instruments predictive of general practice (GP) trainees' subsequently requiring formal remediation. We conducted a retrospective cohort study of trainees from a large Australian regionally-based GP training organization. The outcome factor was requirement for formal remediation. Independent variables were demographic factors and a range of formative assessments conducted immediately prior to or during early-stage training. Analyses employed univariate and multivariate logistic regression of each predictor assessment modality with the outcome, adjusting for potential confounders. Of 248 trainees, 26 (10.5 %) required formal remediation. Performance on the Colleague Feedback Evaluation Tool (entailing feedback from a trainee's clinical colleagues on clinical performance, communication and probity) and External Clinical Teaching Visits (half-day sessions of the trainee's clinical consultations observed directly by an experienced GP), along with non-Australian primary medical qualification, were significantly associated with requiring remediation. There was a non-significant trend for association with performance on the Doctors Interpersonal Skills Questionnaire (patient feedback on interpersonal elements of the consultation). There were no significant associations with entry-selection scores or formative exam or assessment scores. Our finding that 'in vivo' assessments of complex behaviour, but not 'in vitro' knowledge-based assessments, predict need for remediation is consistent with theoretical understanding of the nature of remediation decision-making and should inform remediation practice in GP vocational training.

Management of testosterone therapy in adolescents and young men with hypogonadism: are we following adult clinical practice guidelines?

PubMed

Nahata, Leena; Yu, Richard N; Bhasin, Shalender; Cohen, Laurie E

2015-05-01

Male hypogonadism is a common disorder that is associated with low bone density, poor muscle mass, anemia, and sexual dysfunction. The Endocrine Society recently published a Clinical Practice Guideline for testosterone therapy in androgen-deficient men. Because treatment is frequently initiated in adolescence, the goal of this quality improvement initiative was to assess whether pediatric endocrinologists at a large tertiary care center follow these guidelines and to identify opportunities for improvement. We performed a retrospective chart review at Boston Children's Hospital. Inclusion criteria were as follows: current age ≥16 years, diagnosis of hypogonadism, and testosterone replacement therapy. Data were collected about current age, age at treatment initiation, diagnoses, pre- and on-treatment testosterone levels, route of testosterone administration and dose, bone density, hematocrit levels, and adherence with therapy. Fifty-nine patients were included. Fourteen (24%) were prescribed lower testosterone doses than those recommended in the Clinical Practice Guideline. Seven (12%) had no pre-treatment testosterone levels, and 10 (17%) had no on-treatment levels. In 49 patients with on-treatment testosterone levels, 36 had at least one value that was lower than the adult reference range. Ten (28%) of the 36 men with low testosterone levels had no dose adjustments. Thirty-seven (63%) of the 59 patients had no dual-energy X-ray absorptiometry scans, and 18 (31%) did not have hematocrit levels. Pediatric endocrinologists in this review did not consistently follow the Clinical Practice Guideline for testosterone therapy in hypogonadal adult males. Strategies that improve adherence to guidelines could help maximize the benefits of therapy and minimize treatment-associated risks.

Warfarin Pharmacogenetics

PubMed Central

Johnson, Julie A.; Cavallari, Larisa H.

2014-01-01

The cytochrome P450 (CYP) 2C9 and vitamin K epoxide reductase complex 1 (VKORC1) genotypes have been strongly and consistently associated with warfarin dose requirements, and dosing algorithms incorporating genetic and clinical information have been shown to be predictive of stable warfarin dose. However, clinical trials evaluating genotype-guided warfarin dosing produced mixed results, calling into question the utility of this approach. Recent trials used surrogate markers as endpoints rather than clinical endpoints, further complicating translation of the data to clinical practice. The present data do not support genetic testing to guide warfarin dosing, but in the setting where genotype data are available, use of such data in those of European ancestry is reasonable. Outcomes data are expected from an on-going trial, observational studies continue, and more work is needed to define dosing algorithms that incorporate appropriate variants in minority populations; all these will further shape guidelines and recommendations on the clinical utility of genotype-guided warfarin dosing. PMID:25282448

Clinical recommendations of cardiac magnetic resonance, Part I: ischemic and valvular heart disease: a position paper of the working group 'Applicazioni della Risonanza Magnetica' of the Italian Society of Cardiology.

PubMed

Aquaro, Giovanni Donato; Di Bella, Gianluca; Castelletti, Silvia; Maestrini, Viviana; Festa, Pierluigi; Ait-Ali, Lamia; Masci, Pier Giorgio; Monti, Lorenzo; di Giovine, Gabriella; De Lazzari, Manuel; Cipriani, Alberto; Guaricci, Andrea I; Dellegrottaglie, Santo; Pepe, Alessia; Marra, Martina Perazzolo; Pontone, Gianluca

2017-04-01

Cardiac magnetic resonance (CMR) has emerged as a reliable and accurate diagnostic tool for the evaluation of patients with cardiac disease in several clinical settings and with proven additional diagnostic and prognostic value compared with other imaging modalities. This document has been developed by the working group on the 'application of CMR' of the Italian Society of Cardiology to provide a perspective on the current state of technical advances and clinical applications of CMR and to inform cardiologists on how to implement their clinical and diagnostic pathways with the inclusion of this technique in clinical practice. The writing committee consisted of members of the working group of the Italian Society of Cardiology and two external peer reviewers with acknowledged experience in the field of CMR.

Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study.

PubMed

Jefford, Elaine; Fahy, Kathleen

2015-05-01

clinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from 'non-scientific' occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology. to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour? twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted. using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data. over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes 'intuition' as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated. Copyright © 2015 Elsevier Ltd. All rights reserved.

Intervention Fidelity: Aspects of Complementary and Alternative Medicine (CAM) Research

PubMed Central

Wyatt, Gwen; Sikorskii, Alla; Rahbar, Mohammad Hossein; Victorson, David; Adams, Lora

2010-01-01

Background The Treatment Fidelity Workgroup (TFW) established by the National Institutes of Health (NIH) provides a 5-point structure for intervention fidelity: dosing, interventionists’ consistency, intervention delivery, receipt and enactment of the intervention. Using our reflexology trial, we apply the first three points. Objectives Study objectives are to: 1) evaluate key dosage dimensions associated with CAM research; 2) evaluate approaches to interventionists’ consistency of delivery of CAM protocols; and 3) evaluate and discuss data that reflect CAM intervention fidelity. Intervention Women with late stage breast cancer (N=318) were randomly assigned to either 4 weeks of reflexology, placebo, or standard care. Results Dosing consists of three dimensions: frequency (4-sessions), duration (30 minutes), and interval between sessions (5–9 days). Interventionist consistency revealed over a 90% accuracy rate in following the protocol; 84% and 89% completion rate of the 4 session in the reflexology and placebo groups respectively; and no differences in attrition after randomization between reflexology and placebo groups (17% and 15%, respectively). Intervention delivery, examined through debriefing data, indicated a significantly higher rate of correct guesses on group assignment in the reflexology group as compared to the placebo (82% versus 46%, p-value=.0002). Conclusions This study points out the relevance of dosing, interventionists’ consistency, and delivery data within a CAM clinical trial, as well as the challenges of blinding. Implications Monitoring intervention fidelity by using the key areas identified by the BCC ensures that findings from a clinical trial are meaningful and have the potential to be translated to clinical practice. PMID:20467309

Baseline characteristics and interim (3-month) efficacy and safety data from STELLA-LONG TERM, a long-term post-marketing surveillance study of ipragliflozin in Japanese patients with type 2 diabetes in real-world clinical practice.

PubMed

Maegawa, Hiroshi; Tobe, Kazuyuki; Tabuchi, Hiromi; Nakamura, Ichiro

2016-10-01

To evaluate the efficacy and safety of ipragliflozin in real-world clinical practice in Japanese patients with type 2 diabetes. We conducted interim analyses at 3 months of a 3-year prospective study of patients who were first prescribed ipragliflozin between 17 July 2014 and 16 October 2015, and whose data were locked by 16 January 2016. Changes in glycemic control, blood pressure, and laboratory variables from baseline, and incidence of adverse drug reactions (ADRs). Of 11,412 patients initially registered, efficacy and safety data were available for 3481 (30.5%) and 4360 (38.2%) patients, respectively. Hemoglobin A1c and fasting plasma glucose decreased by 0.67% and 28.8 mg/dL, respectively, at 3 months/last assessment (both P < .001) from baseline (8.00% and 166.4 mg/dL, respectively). Blood pressure and lipid levels also improved significantly. There were 258 ADRs in 194 patients. The ADRs included 'renal and urinary disorders' (system organ class) in 110 patients (2.5%). These 3-month interim results indicate that ipragliflozin improved glycemic control, lipids, and blood pressure with low rates of ADRs in Japanese patients with type 2 diabetes in real-world clinical practice. The results were consistent with those of placebo-controlled, randomized clinical trials. Clinicaltrials.gov identifier: NCT02479399.

Comparing the Quality of Ambulatory Surgical Care for Skin Cancer in a Veterans Affairs Clinic and a Fee-For-Service Practice Using Clinical and Patient-Reported Measures.

PubMed

Dizon, Matthew P; Linos, Eleni; Arron, Sarah T; Hills, Nancy K; Chren, Mary-Margaret

2017-01-01

The Institute of Medicine has identified serious deficiencies in the measurement of cancer care quality, including the effects on quality of life and patient experience. Moreover, comparisons of quality in Veterans Affairs Medical Centers (VA) and other sites are timely now that many Veterans can choose where to seek care. To compare quality of ambulatory surgical care for keratinocyte carcinoma (KC) between a VA and fee-for-service (FFS) practice, we used unique clinical and patient-reported data from a comparative effectiveness study. Patients were enrolled in 1999-2000 and followed for a median of 7.2 years. The practices differed in a few process measures (e.g., median time between biopsy and treatment was 7.5 days longer at VA) but there were no substantial or consistent differences in clinical outcomes or a broad range of patient-reported outcomes. For example, 5-year tumor recurrence rates were equally low (3.6% [2.3-5.5] at VA and 3.4% [2.3-5.1] at FFS), and similar proportions of patients reported overall satisfaction at one year (78% at VA and 80% at FFS, P = 0.69). These results suggest that the quality of care for KC can be compared comprehensively in different health care systems, and suggest that quality of care for KC was similar at a VA and FFS setting.

Update on Medical Practices that should be questioned in 2015

PubMed Central

Morgan, Daniel J.; Dhruva, Sanket S.; Wright, Scott M.; Korenstein, Deborah

2016-01-01

Importance Overuse of medical care, consisting primarily of overdiagnosis and overtreatment, is a common clinical problem. Objective To identify and highlight articles published in 2014 that are most likely to impact overuse, organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse. These manuscripts were reviewed and interpreted for their importance to clinical medicine. Evidence Review A structured review of English-language articles on PubMed published in 2014 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults. Findings We reviewed 910 articles, of which 440 addressed overuse. Of these, 104 were deemed most relevant based on the presentation of original data, quality of methodology, magnitude of clinical impact, and the number of patients potentially affected. The 10 most influential articles were selected by author consensus using the same criteria. Findings included lack of benefit for screening pelvic examinations (positive predictive value <5%), carotid artery and thyroid ultrasounds. Harms of cancer screening included unnecessary surgery and complications. Head CT scans were an overused diagnostic test (4% with clinically significant findings) and overtreatment included acetaminophen for low back pain, prolonged opioid use after surgery (3% of patients on >90 days), perioperative aspirin, medications to increase HDL, and stenting for renal artery stenosis. Conclusions and Relevance Many common medical practices should be reconsidered. It is hoped that our review promotes reflection on these 10 articles and lead to questioning other non-evidence based practices. PMID:26551354

Behavioral Health Integration into Primary Care: a Microsimulation of Financial Implications for Practices.

PubMed

Basu, Sanjay; Landon, Bruce E; Williams, John W; Bitton, Asaf; Song, Zirui; Phillips, Russell S

2017-12-01

New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities. To evaluate the financial impact for primary care practices of integrating behavioral health services. Microsimulation model. We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey. A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist. Net revenue change per full-time physician. When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types. New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.

Report on the RCDS-CDHSRU workshop on developing clinical guidelines/standards of practice.

PubMed

Leake, J L; Main, P A; Woodward, G L

1996-07-01

Investigators from the Community Dental Health Services Research Unit (CDHSRU) held a workshop to test a model for developing clinical guidelines/standards of practice, which are required under the Regulated Health Professions Legislation. Forty-two individuals from Ontario and Canada, including dentists, representatives of the public, and professionals, participated in the three-day workshop, held under the auspices of the quality assurance committee of the Royal College of Dental Surgeons of Ontario (RCDS). Through direct experience, workshop participants sought to learn each of the steps, as defined by the literature, involved in clinical guideline development. Ultimately, they hoped to recommend steps for RCDS to follow in developing standards of practice. To ensure that a realistic and valid model emerged from the workshop, a real topic, namely the management of smooth surface enamel lesions in permanent teeth, was used to develop and test clinical guidelines. Prior to the workshop, participants were sent literature on one of five aspects of the topic, as well as papers describing the methodology of critically appraising the literature, and partially-completed templates outlining the basic steps to be followed. During the first evening and first morning of the workshop, participants listened to presentations on the development of clinical guidelines, the prevalence of smooth surface lesions, the role of economics in guideline development, and the necessary considerations in writing clinical guidelines. Under the leadership of trained facilitators, they then worked in small groups to write evidence-based recommendations and report them to the other workshop participants for feedback. Using this feedback, they returned to their groups to revise their recommendations and work on the workshop's overall recommendations to the RCDS. The day concluded in the evening, when the workshop facilitators and coordinators met to edit the groups' recommendations into a consistent format for presentation to all participants. On the second morning, the participants attended a plenary session to review the evidence-based recommendations developed by the groups, as well as their overall recommendations on the steps to be followed by the RCDS. Ultimately, workshop participants partially completed the templates and developed preliminary evidence-based recommendations on the management of enamel smooth-surface caries. Based on their experiences, they recommended a seven-step process for the future development of clinical practice guidelines/standards of practice in Ontario. These steps are recommendations only, and are not RCDS policy.

Health professionals' perceptions about their clinical performance and the influence of audit and feedback on their intentions to improve practice: a theory-based study in Dutch intensive care units.

PubMed

Gude, Wouter T; Roos-Blom, Marie-José; van der Veer, Sabine N; Dongelmans, Dave A; de Jonge, Evert; Francis, Jill J; Peek, Niels; de Keizer, Nicolette F

2018-02-17

Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals' perceptions about their clinical performance and the influence of feedback on their intentions to change practice. We conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals' perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU's own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard. We analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0-100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic. Audit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals' prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice. ClinicalTrials.gov NCT02922101 . Registered 26 September 2016.

Assessing the reliability, predictive and construct validity of historical, clinical and risk management-20 (HCR-20) in Mexican psychiatric inpatients.

PubMed

Sada, Andrea; Robles-García, Rebeca; Martínez-López, Nicolás; Hernández-Ramírez, Rafael; Tovilla-Zarate, Carlos-Alfonso; López-Munguía, Fernando; Suárez-Alvarez, Enrique; Ayala, Xochitl; Fresán, Ana

2016-08-01

Assessing dangerousness to gauge the likelihood of future violent behaviour has become an integral part of clinical mental health practice in forensic and non-forensic psychiatric settings, one of the most effective instruments for this being the Historical, Clinical and Risk Management-20 (HCR-20). To examine the HCR-20 factor structure in Mexican psychiatric inpatients and to obtain its predictive validity and reliability for use in this population. In total, 225 patients diagnosed with psychotic, affective or personality disorders were included. The HCR-20 was applied at hospital admission and violent behaviours were assessed during psychiatric hospitalization using the Overt Aggression Scale (OAS). Construct validity, predictive validity and internal consistency were determined. Violent behaviour remains more severe in patients classified in the high-risk group during hospitalization. Fifteen items displayed adequate communalities in the original designated domains of the HCR-20 and internal consistency of the instruments was high. The HCR-20 is a suitable instrument for predicting violence risk in Mexican psychiatric inpatients.

College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference on good laboratory practices in gynecologic cytology: background, rationale, and organization.

PubMed

Tworek, Joseph A; Henry, Michael R; Blond, Barbara; Jones, Bruce Allen

2013-02-01

Gynecologic cytopathology is a heavily regulated field, with Clinical Laboratory Improvement Amendments of 1988 mandating the collection of many quality metrics. There is a lack of consensus regarding methods to collect, monitor, and benchmark these data and how these data should be used in a quality assurance program. Furthermore, the introduction of human papilloma virus testing and proficiency testing has provided more data to monitor. To determine good laboratory practices in quality assurance of gynecologic cytopathology. Data were collected through a written survey consisting of 98 questions submitted to 1245 Clinical Laboratory Improvement Amendments-licensed or Department of Defense laboratories. There were 541 usable responses. Additional input was sought through a Web posting of results and questions on the College of American Pathologists Web site. Four senior authors who authored the survey and 28 cytopathologists and cytotechnologists were assigned to 5 working groups to analyze data and present statements on good laboratory practices in gynecologic cytopathology at the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference. Ninety-eight attendees at the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference discussed and voted on good laboratory practice statements to obtain consensus. This paper describes the rationale, background, process, and strengths and limitations of a series of papers that summarize good laboratory practice statements in quality assurance in gynecologic cytopathology.

Item generation and pilot testing of the Comprehensive Professional Behaviours Development Log.

PubMed

Bartlett, Doreen J; Lucy, S Deborah; Bisbee, Leslie

2006-01-01

The purpose of this project was to generate and refine criteria for professional behaviors previously identified to be important for physical therapy practice and to develop and pilot test a new instrument, which we have called the Comprehensive Professional Behaviours Development Log (CPBDL). Items were generated from our previous work, the work of Warren May and his colleagues, a competency profile for entry-level physical therapists, our regulatory code of ethics, and an evaluation of clinical performance. A group of eight people, including recent graduates, clinical instructors and professional practice leaders, and faculty members, refined the items in two iterations using the Delphi process. The CPBDL contains nine key professional behaviors with a range of nine to 23 specific behavioral criteria for individuals to reflect on and to indicate the consistency of performance from a selection of "not at all," "sometimes," and "always" response options. Pilot testing with a group of 42 students in the final year of our entry-to-practice curriculum indicated that the criteria were clear, the measure was feasible to complete in a reasonable time frame, and there were no ceiling or floor effects. We believe that others, including health care educators and practicing professionals, might be interested in adapting the CPBDL in their own settings to enhance the professional behaviors of either students in preparation for entry to practice or clinicians wishing to demonstrate continuing competency to professional regulatory bodies.

Practitioners, patients, and their visits: a description of accident and medical (A&M) clinics in New Zealand, 2001/2.

PubMed

Hider, Phil; Lay-Yee, Roy; Davis, Peter

2007-05-18

The National Primary Medical Care survey was undertaken to describe primary health care in New Zealand, including the characteristics of accident and medical (A and M) clinic providers, their practices, the patients they see, the problems presented, and the management offered. Data were collected from a 50% random sample of all A and M clinics in New Zealand as part of the National Primary Medical Care survey carried out in 2001/2. Data were obtained from 12 A and M clinics throughout New Zealand between usual hours (Monday-Friday 8 am-6 pm) and at other times. A and M clinics were staffed by an average of 2.7 full-time equivalent (FTE) A and M practitioners . Most clinics operated as a limited liability company. The majority of A and M practitioners were male and aged between 35-44 years. On average, A and M doctors had been in practice for over 10 years and had been in the sampled practice for only 2.9 years. More than a third of doctors had not trained in New Zealand. The doctors worked, on average, 6.3 half days and saw nearly 90 patients per week. The findings suggest that young patients and a diverse ethnic range attend A and M practices. Community Services Card holders were not usual patients. Few patients had an ongoing relationship with the practices. Most visits related to a single, new, and short-term problem that was often an injury or a respiratory illness. About a fifth of visits were associated with an order for an investigation or an X-ray, fewer investigations were arranged outside usual hours. About half the visits resulted in a prescription but more visits outside normal hours received pharmacological treatment and the number of items was higher. The most frequently prescribed items were antibiotics and analgesics. Follow-up was arranged for between a third to a half of visits, depending on the time of day. Referrals were often made to non-medical destinations. While patient and visit characteristics were generally similar regardless of whether the visit occurred during usual working hours or at other times, some differences were apparent in the type of problems that were presented out of hours and their management. The main impression is that the medical A and M clinics provide episodic treatment for relatively young patients mainly related to a new, short-term problem, particularly an injury or a respiratory illness. This picture is consistent with previous research and the role of similar clinics overseas. Further work is needed to compare A and M clinics with established general practice in relation to the services that are provided as well as the acceptability and quality of these services.

Portuguese version of the EUROPEP questionnaire: contributions to the psychometric validation

PubMed Central

Roque, Hugo; Veloso, Ana; Ferreira, Pedro L

2016-01-01

ABSTRACT OBJECTIVE To assess the construct validity and reliability of the Portuguese version of the European Task Force on Patient Evaluation of General Practice Care questionnaire. METHODS We applied the Portuguese version of the European Task Force on Patient Evaluation of General Practice Care to 392 users of 20 Family Health Units from the North of Portugal. The validity of the construct was evaluated by exploratory factor analysis, with the Principal Axis Factoring method, by orthogonal rotation (varimax procedure), by the Kaiser normalization criteria (eigenvalue ≥ 1). The factorability of the data matrix was verified by the Kaiser-Meyer-Olkin and Bartlett’s sphericity test. We estimated the reliability by the indicator of internal consistency Cronbach’s alpha. To analyze the correlations between satisfaction and loyalty, we used the Pearson correlations. The predictor effect of satisfaction on loyalty was analyzed by simple linear regression. RESULTS Satisfaction presented five robust and well individualized dimensions – medical care, nursing care, clinical secretariat services, accessibility, and organization of services – with alpha values between 0.86 and 0.97, good levels of internal consistency. The loyalty showed alpha value of 0.72, considered a reasonable internal consistency. The satisfaction was predictive of loyalty. CONCLUSIONS The Portuguese European Task Force on Patient Evaluation of General Practice Care questionnaire is a robust and reliable instrument to measure the satisfaction and loyalty of users of the Family Health Units. PMID:27706374