scholarly journals Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative

2016 ◽  
Vol 21 (1) ◽  
pp. 54-65 ◽  
Author(s):  
Rima Abdouni ◽  
Teri Reyburn-Orne ◽  
Tarek H. Youssef ◽  
Imad Y. Haddad ◽  
Richard D. Gerkin
Keyword(s):  
Clinical Practice ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Opioid Dependence ◽  
Phase 1 ◽  
Tertiary Care ◽  
Treatment Guideline ◽  
Quality Improvement Initiative ◽  
Phase 2 ◽  
Baseline Phase

OBJECTIVES: To determine whether utilization of a hospital-based clinical practice guideline for the care of pediatric iatrogenic opioid dependence (IOD) would promote a decrease in opioid exposure and improve management of opioid abstinence syndrome (AS). METHODS: This study is a retrospective chart review of critically ill patients from a tertiary care children's hospital. Inclusion criteria included mechanically ventilated patients up to 18 years of age who received continuous opioid infusions for at least 7 days and any length of methadone administration. Data on IOD patients from January 2005 to June 2010 was divided into 3 periods: baseline, phase 1, and phase 2. Primary outcome was decrease in opioid exposure, measured by methadone duration of use and any additional opioid bolus doses used in AS management. Documentation of additional opioid bolus doses was regarded as a surrogate measure of AS. Secondary outcomes included total cumulative fentanyl dose, continuous fentanyl infusion duration of use, and hospital and pediatric intensive care unit length of stay. RESULTS: There was a significant decrease in methadone duration of use in IOD patients from 15.3 ± 8.7 days at baseline to 9.5 ± 3.7 days during phase 1 (p = 0.002), to 8.1 ± 3.7 days on phase 2 (reduction not significant, p = 0.106) of this evaluation. Additional opioid bolus doses were significantly lower from baseline to phase 1 (5.5 ± 5.1 vs. 1.8 ± 2.3, p = 0.001) and from phase 1 to phase 2 (1.8 ± 2.3 vs. 0.2 ± 1.5, p = 0.003). For the remaining outcomes, differences were not observed among the evaluation periods, except for the total cumulative fentanyl dose, which was reduced from 2.8 ± 3.7 mg/kg at baseline to 1 ± 1 mg/kg only during phase 1 (p = 0.017). CONCLUSIONS: Introduction of a standardized, hospital-based clinical practice guideline for children with IOD reduced the length of exposure to opioids and improved opioid AS management.

Management of testosterone therapy in adolescents and young men with hypogonadism: are we following adult clinical practice guidelines?

2015 ◽  
Vol 28 (5-6) ◽  
Author(s):  
Leena Nahata ◽  
Richard N. Yu ◽  
Shalender Bhasin ◽  
Laurie E. Cohen
Keyword(s):  
Clinical Practice ◽  
Bone Density ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Tertiary Care ◽  
Testosterone Replacement Therapy ◽  
Male Hypogonadism ◽  
Testosterone Therapy ◽  
Endocrine Society ◽  
Testosterone Levels

AbstractMale 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.

scholarly journals MP05: Validation of the Canadian clinical practice guideline clinical decision aid for acute aortic syndrome

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S43-S44
Author(s):  
B. Paige ◽  
A. Maeng ◽  
D. Savage ◽  
R. Ohle ◽  
MBBCh MA
Keyword(s):  
Computed Tomography ◽  
Clinical Practice ◽  
High Risk ◽  
Confidence Intervals ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.

scholarly journals Assessment of Hypercalcemia Management at an Academic Institution

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A255-A255
Author(s):  
Jodi Nagelberg ◽  
Robert Hakim ◽  
Brad Kimura ◽  
Karen C McCowen ◽  
Shanna Block
Keyword(s):  
Clinical Practice ◽  
Serum Creatinine ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Academic Medical Center ◽  
Treatment Guideline ◽  
Hospitalized Patients ◽  
Post Treatment ◽  
Serum Phosphorus ◽  
Severe Hypercalcemia

Abstract Background: Currently, there is no widely accepted clinical practice guideline for the management of severe hypercalcemia in hospitalized patients. Objective: The purpose of this project was to analyze management of hypercalcemia in hospitalized patients at an academic medical center, then establish and implement a clinical practice guideline for hypercalcemia treatment. Design: Retrospective chart review of all patients admitted for management of hypercalcemia over 37 consecutive months. Setting: Urban academic tertiary referral center Measurements: We examined which calcium- lowering medications were used, how often 2 medications were needed, average time to normocalcemia, incidence of hypocalcemia post treatment, serum phosphorus nadir and serum creatinine peak. We also assessed medication appropriateness (dose and frequency). Results: Seventy-two patients were included; 58 patients with hypercalcemia of malignancy and 14 patients with hypercalcemia of other diagnoses. In the malignancy group the most common treatment was a combination of calcitonin + bisphosphonate (43%), followed by bisphosphonate alone (29%) and calcitonin alone (24%). In the non-malignancy group, calcitonin alone was used in 50%, calcitonin + bisphosphonate in 21% and a bisphosphonate alone in 14%. Denosumab was rarely used in both groups. The median time to normocalcemia was 3.0 days irrespective of diagnostic group. Seventy two percent of the patients with malignancy and 86% of the non-malignancy group achieved normocalcemia. The incidence of hypocalcemia was 21% (12/58) in the malignancy subgroup and 29% (4/14) in the others after treatment. Serum creatinine did not change from baseline to post-treatment in either population. Median serum phosphorus dropped from 2.9 mg/dL to 1.8 mg/dL in the malignancy group and 4.2 mg/dL to 2.1 mg/dL in the non-malignancy group. Only 41% of patients that received calcitonin, were given recommended dose, route, and frequency. Conclusion: Based on the results of this study, a hypercalcemia treatment guideline was developed, highlighting appropriate medication dose and frequency. This guideline recommends zoledronic acid alone for asymptomatic malignancy patients, and in combination with calcitonin for symptomatic patients. In contrast, calcitonin alone is considered first line for non-malignant conditions.

Quality Assessment of the Clinical Practice Guideline for Tympanostomy Tubes in Children

2018 ◽  
Vol 159 (5) ◽  
pp. 914-919 ◽  
Author(s):  
Joshua J. Sturm ◽  
Phillip Huyett ◽  
Amber Shaffer ◽  
Dennis Kitsko ◽  
David H. Chi
Keyword(s):  
Clinical Practice ◽  
Otitis Media ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Otitis Media With Effusion ◽  
Tertiary Care ◽  
Acute Otitis Media ◽  
Case Series ◽  
Annual Number ◽  
Tympanostomy Tubes

Objectives To determine the association between the introduction of statements 6 and 7 in the 2013 clinical practice guideline (CPG) for tympanostomy tubes in children and the identification of preoperative middle ear fluid (acute otitis media / otitis media with effusion [AOM/OME]) in children undergoing bilateral myringotomy and tube (BMT) placement. Study Design Case series with chart review. Setting Tertiary care children’s medical center. Subjects and Methods Patients who underwent BMT for recurrent AOM were retrospectively reviewed. We examined 240 patients before (BG; 2012) and 240 patients after (AG; 2014) the introduction of the CPG. Results The baseline characteristics of the 2 groups were comparable. The total annual number of BMT placements performed at our institution decreased from 3957 (BG) to 3083 (AG). There was no significant increase in the rate of preoperative AOM/OME identification following CPG introduction (BG 78.3% vs AG 83.3%, P = .164). The rate of identification of AOM/OME in the operating room (OR) increased from 54.2% (BG) to 71.3% (AG, P < .001). The rate of identification of AOM/OME both in the clinic and in the OR increased from 55.1% (BG) to 71.3% (AG, P < .001). Cases with concordant clinic and OR AOM/OME occurred among younger children ( P = .045), those with fewer episodes of AOM ( P = .043), and those with shorter time between the clinic and OR dates ( P = .008). Conclusions Following the introduction of the CPG, there was no change in the rate of identification of AOM/OME prior to recommending BMT placement in children with recurrent AOM. The lack of improved compliance with statements 6 and 7 may be related to multiple clinician- and patient-derived factors.

A prospective study of an inpatient febrile neutropenia clinical practice guideline in oncology patients.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 114-114
Author(s):  
Tri Minh Le ◽  
Tanya Thomas ◽  
Joshua Reuss ◽  
Gina Degennaro ◽  
Elizabeth Daniels ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Febrile Neutropenia ◽  
Prospective Study ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Tertiary Care ◽  
Antibiotic Administration ◽  
Oncology Patients ◽  
Significant Difference ◽  
Historical Controls

114 Background: Febrile neutropenia (FN) is a common complication in oncology patients and is associated with significant morbidity and mortality if untreated. Because of this, it is regarded as a medical emergency. FN treatment guidelines universally recommend the prompt initiation ( < 60 minutes) of intravenous antibiotic therapy. We hypothesized that a quality initiative project creating a new FN clinical practice guideline (CPG) would reduce the time to antibiotic administration (TTA) for inpatient oncology patients with FN. Methods: This prospective study compared patients diagnosed with an initial episode of FN (4/2015-8/2015) with historical controls (4/2013-8/2013) on an inpatient oncology floor at a tertiary care academic hospital. Interventions included the development of an institutional CPG which standardized the definition of FN, implementation of a new clinical workflow, creation of education sessions for LIP’s and RN’s, and creation of an electronic FN order set. The primary outcome was TTA, with target goal being < 60 minutes from the onset of fever. Secondary outcomes included time to antibiotic order, need for ICU care, and 30-day mortality. P-values were calculated using a chi-square test. Results: In total, 31 consecutive FN episodes were observed over the 5-month study period. The median TTA decreased from 112 minutes in 2013 to 37.5 minutes in 2015 (p < 0.001). 30/31 (97%) patients in the 2015 group had their antibiotics ordered within 60 minutes vs 14/22 (64%) in 2013 (p = 0.002). 26/31 (84%) patients in the 2015 group had antibiotics administered within 60 minutes vs 4/22 (18%) in 2013 (p < 0.001). There was no significant difference in need for ICU care (16% in 2015 vs 9% in 2013, p = NS) or 30-day mortality (6% in 2015 vs 5% in 2013, p = NS). Conclusions: The inpatient FN CPG is a significant quality improvement initiative that has shown significant improvements in TTA. We were able to demonstrate value by a significant decrease in median TTA compared to historical controls with a significantly increased percentage of patients having both antibiotics ordered and administered within 60 minutes. In our cohort of patients, no significant differences were noted in rates of ICU care or 30-day mortality.

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