Duncan McKenzie

Clinical Pathway and Monthly Feedback Improve Adherence to Antibiotic Guideline Recommendations for Community-Acquired Pneumonia

Background Compliance with community-acquired pneumonia (CAP) guidelines remains poor despite a substantial body of evidence indicating that guideline-concordant care improves patient outcomes. The aim of this study was to compare the relative effectiveness of a general educational and a targeted emergency department intervention on improving physicians’ concordance with CAP guidelines. Methods Two distinct interventions were implemented over specific time periods. The first intervention was educational, focusing on the development of local CAP guidelines and their dissemination through hospital-wide educational programmes. The second intervention was a targeted one for the emergency department, where a clinical pathway for the initial management of CAP patients was introduced, followed by monthly feedback to the emergency department (ED) physicians about concordance rates with the guidelines. Data on the concordance rate to CAP guidelines was collected from a retrospective chart review. Results A total of 398 eligible patient records were reviewed to measure concordance to CAP guidelines over the study period. Concordance rates during the baseline and educational intervention periods were similar (28.1% vs. 31.2%; p > 0.05). Significantly more patients were treated in accordance with the CAP guidelines after the ED focused intervention when compared to the baseline (61.5% vs. 28.1%; p < 0.05) or educational period (61.5% vs. 31.2%; p < 0.05). Conclusions A targeted intervention with a CAP clinical pathway and monthly feedback was a successful strategy to increase adherence to empirical antibiotic recommendations in CAP guidelines.

Prevention of venous thromboembolism amongst patients in an acute tertiary referral teaching public hospital: a best practice implementation project

Background:Deep vein thrombosis and pulmonary embolism are known collectively as venous thromboembolism (VTE). These conditions are possible complications in hospitalized patients that can extend hospital stay, result in unplanned readmission, and are associated with long-term disability and death. Despite strong evidence, many patients do not receive optimal thromboprophylaxis. VTE prevention is a top priority in healthcare systems worldwide. Aim:The aim of the project was to establish a standardized hospital-wide VTE prevention program and to improve awareness of, and compliance with, best practice standards in the prevention of VTE. Methods:A multidisciplinary team utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System program to facilitate the collection of pre and post implementation audit data. The Getting Research into Practice program was also used to conduct a situational analysis to identify barriers, enablers, and implementation strategies while taking into account the context in which the changes were to occur. Hospital-acquired VTE data were collected to monitor the impact, if any, on patient outcomes. The project was conducted in three different phases over a 2.5-year period in an acute care public hospital. Results:A comprehensive suite of professionally crafted guidelines, tools, and resources were developed to facilitate clinician acceptance of evidence-based practices. Comparison of compliance results showed variable improvements with four audit criteria. Formalized patient risk assessment improved to 7.5% with the introduction of a new form. High-risk patients receiving appropriate prophylaxis improved to 81% in medical and 83% in surgical patients, on an existing high background compliance rate. A total of 59% of staff attended a VTE update education in-service. No patients received information about adverse VTE events prior to discharge. The hospital-acquired VTE rate decreased slightly from 0.65 to 0.52 events per 1000 overnight bed days. Conclusion:Overall the project achieved improvements in compliance with best practice standards. A number of delays and barriers contributed to some of the planned interventions not being fully implemented at the time of the follow-up audit. Contributing factors included the lack of electronic capabilities, some processes not being fully embedded into routine clinical workflows, lack of staff time, and identification of an additional organizational barrier relating to practical issues in providing patient education at discharge. A second action cycle is recommended in an attempt to further improve compliance, ensure intervention fidelity, and embed practices into routine daily workflows to positively impact patient and organizational outcomes.

Can homemade fit testing solutions be as effective as commercial products

Abstract Background Fit testing is used to determine whether a N95 mask will provide respiratory protection for the wearer by preventing inhalation of airborne transmitted microorganisms. National guidelines recommend that healthcare workers (HCW) who use N95 masks require fit testing. Quantitative fit testing requires the purchasing and use of fit testing solutions and associated equipment. In high volume, these solutions are expensive and may not be readily available, as was seen in the 2009 H1N1 influenza pandemic. The aim of this study was to determine how a homemade solution compared against a commercially available product and a placebo. Methods Afit test was performed on the same person, on three separate occasions, using three different solutions – commercial (45% sodium saccharin), homemade (to be disclosed) and placebo (water). The solution was double blinded and solutions were chosen and administered in a random order. Results Atotal of 48 people participated in this study.At the threshold testing stage, 8.3% did not taste any solution, 16.7% of people could taste the placebo, 89.6% could taste the commercial solution and 91.7% could taste the homemade solution. All persons who could taste the commercial solution could taste homemade solution. Conclusion The findings of our study suggest that fit testing solutions could be made locally with a similar effect to that of commercial products, that quantitative fit testing is unreliable and that serious consideration should be given to the role of quantitative fit testing in future guidelines and standards. We recommend that this study be conducted on a larger scale to support our findings.