Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department

textabstractAcute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children’s hospital in The Netherlands ( 2010–2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09–4.31 p < 0.05). We observed no differences in other outcome measures. Conclusion: Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures.(Table presented.

Nurse Practitioners Use of Clinical Decision Support Tools in Heart Failure

Abstract Background: Heart failure (HF) is a progressive disorder which results in poor patient outcomes for those affected. Although there are evidence-based medications to alter the progression and improve outcomes, provider adherence to these medications has been suboptimal. Clinical decision support tools (CDS) within the electronic medical record are effective tools in medical management. Objective: The primary objective was to evaluate the use of CDS to nurse practitioners (NPs) adherence of guideline-directed medical therapy in HF patients in the outpatient setting. The secondary objective was to assess the NPs perception of facilitators and barriers that may affect the use of CDS. Methods: A retrospective chart review was performed to extract HF measures and preventative care processes documented during an 18-month period by two NPs at two local primary care clinics in Southeast U.S. Descriptive analysis of the chart data was performed to compare the results of the Centers for Medicare and Medicaid (CMS) National performance quality indicators. Additional data was obtained from questionnaires that assess NPs perceptions and factors that affect the use of CDS. Results: Collectively, the NPs performance fell below CMS results. However, one NP exceeded CMS indicators in all areas except blood pressure control. Although the NPs had some knowledge of CDS, CDS was not used with each patient contact. The satisfaction of CDS among the NPs was mixed. Conclusion: CDS use was not verified as a driving factor to the low-performance results as the use of CDS among the NPs was low. Initiation or adjustment of HF therapy by the NPs could not be verified within this QIP. Provider education of GDMT and CDS is key to improving HF outcomes. Further research using pre- and post-intervention analysis is warranted

Development of an inventory to assess perceived barriers related to PKU treatment

Background: According to studies of phenylketonuria (PKU), the Brazilian population’s metabolic control shows unsatisfactory indexes from childhood. Research on patients’ perceived difficulties or barriers to adherence to treatment can help us to comprehend how these outcomes are associated. The present study aimed to: (1) describe the development of an inventory for identifying the most frequent and relevant perceived barriers to PKU treatment from the perspective of patients, caregivers, and healthcare professionals; (2) evaluate certain psychometric characteristics of the new measure; and, (3) explore potential predictors (sociodemographic and medical characteristics) that may contribute to increasing the number of perceived barriers and examine whether the number of barriers is associated with the degree of adherence shown by the patient. Results: Participants in the study were 23 patients with PKU (M age = 18.0 years; SD = 7.3; range 6 to 34 years; 69% early-treated) in classical (n = 11) and mild (n = 12) form, and 11 caregivers. The inventory, developed to ascertain perceived barriers to treatment, was completed by patients (≥ 13 years) and caregivers of patients aged 6 to 17 years. Analyses were conducted to investigate whether barrier inventory scores were associated with adherence to treatment as measured by phenylalanine levels in patients’ medical records. Scores on the inventory differed across the patient age groups: adolescents had lower scores (i.e. reported fewer barriers) compared with those of adults (U = 8.000, p = 0.008); patients with better recent metabolic control also reported fewer perceived barriers than did patients with poor adherence (U = 20.000, p = 0.009); and the number of perceived barriers was positively associated with recent blood phenylalanine concentration (Kendall’s taub = 0.41; p = 0.001). Conclusions: These results suggest that the inventory has merit in assessing perceived barriers and support the need for further research on barriers perceived by PKU patients

Fatores percebidos pelos pacientes como barreira à adesão ao tratamento da fenilcetonúria no Brasil

A Fenilcetonúria (PKU) é um erro inato do metabolismo que afeta a atividade de uma enzima responsável pela assimilação da Fenilalanina (Phe). Assim, o tratamento consiste em restringir consideravelmente o consumo de proteínas (que contém grandes concentrações de Phe) desde as primeiras semanas de vida do paciente, para que não haja acúmulo dessa substância no sangue e, consequentemente, no cérebro, o que previne danos cognitivos graves e permanentes. O tratamento deve ser adotado por toda a vida, pois evidências mostram que, mesmo após o período de desenvolvimento cerebral, o excesso de Phe pode levar a prejuízos no funcionalmente intelectual, convulsões, tremores e alterações de humor, afetando a qualidade de vida do indivíduo com a doença. No entanto, segundo estudos com pacientes brasileiros, seus controles metabólicos têm apresentado índices insatisfatórios desde a infância tornando-se piores na idade adulta. Assim, para investigar os possíveis fatores associados à adesão insuficiente nessa população, foram avaliados dados sociodemográficos, histórico de adesão em idades precoces, funcionamento cognitivo e número de barreiras percebidas sobre o tratamento. Participaram do estudo 23 pacientes, com idade média de 18 anos (DP = 7,3; entre 6 a 34 anos de idade), a maioria com PKU Clássica ou Leve, e 11 cuidadores. No capítulo II, o estudo descreve o desenvolvimento de uma ferramenta de avaliação para medir as barreiras percebidas ao tratamento de PKU, que posteriormente foi respondida por pacientes e cuidadores. Em seguida, as respostas foram quantitativa e qualitativamente analisadas para avaliar se seus escores estavam associados à adesão. O Capítulo III descreve a investigação de outros fatores que poderiam impactar na adesão ao tratamento entre esses mesmos pacientes. O sexo do paciente, o início precoce ou tardio do tratamento e o nível de instrução dos cuidadores não influenciaram na adesão. Por outro lado, uma diferença foi encontrada entre pacientes com PKU Clássica em comparação ao grupo com PKU Leve. Também se observou um aumento da Phe plasmática a partir dos 8 anos até os 12 anos de idade no grupo de baixa adesão. Combinando os resultados dos dois estudos, sugere-se que os adultos estão em maior risco para as barreiras percebidas relacionadas ao tratamento dietético da PKU. As barreiras percebidas estiveram relacionadas a um pior controle dos níveis de Phe, o que corrobora a hipótese de associação entre barreiras e não adesão. Pacientes com menor nível de tolerância à Phe e aqueles que apresentam mais dificuldades quanto às demandas de tratamento podem estar mais vulneráveis a uma baixa adesão. Os resultados também reforçam a recomendação de que, ao primeiro sinal de um baixo controle metabólico em idades precoces, uma intervenção multidisciplinar deve ser colocada em prática, a fim de buscar o retorno a valores de Phe dentro dos recomendados o quanto antes.Phenylketonuria (PKU) is an inborn error of metabolism that affects the activity of an enzyme responsible for metabolizing phenylalanine (Phe). Thus, the treatment consists in restricting considerably the consumption of proteins since the first weeks of the patient's life, so that there is no accumulation of this substance in the blood and consequently in the brain, which prevents severe and permanent cognitive impairment. Treatment should be adopted for life long, since evidence has shown that, even after the brain development period, excess Phe may lead to cognitive deficits, seizure, tremors and mood swings, thus affecting the patient's quality of life. However, according to studies with Brazilian patients, their metabolic control presented unsatisfactory indexes since childhood and gets worse in adulthood. So, to investigate possible factors associated with concurrent poor adherence in this population, sociodemographic, history of adherence at early ages, cognitive functioning and number of perceived barriers to the treatment were investigated. 23 patients participated in the study, mean age 18.0 years old (SD = 7.3; 6 to 34), mostly with Classic and Mild PKU and 11 caregivers. In chapter II the study describes the development of an assessment tool to measure perceived barriers to PKU treatment, which was answered by patients and caregivers. Then, answers were qualitatively and quantitatively analyzed to evaluate if its scores were associated with adherence. Chapter III describes the investigation of other factors that could impact on adherence to Phenylketonuria (PKU) treatment among these patients. Patient's gender, early or late onset of treatment, and the caregivers’ level of education did not influence adherence in the study sample. On the other hand, a difference was found between patients with Classical PKU in comparison to the group with Mild PKU. A significant increase in blood Phe was observed from 8 years old up to 12 years of age in the poor adherence group, being a predictor of concurrent adherence. Combining the results of the two studies, it suggested that adults are in higher risk to perceived barriers related to the dietary treatment of PKU. Perceived barriers are related to worst control of phenylalanine levels, which corroborates with the hypothesis of association between barriers and nonadherence. Patients with a lower tolerance level to Phe and those who present more difficulties regarding the treatment demands may be more vulnerable to a poor adherence. It also reinforces the recommendation that, at the first sign of poor adherence at early ages, a multidisciplinary intervention can be put into action in order to seek the return of Phe values within the appropriate ones as soon as possible

Evaluation of Primary Care Providers\u27 Utilization of Angiotensin-Converting Enzyme Inhibitor Therapy in Heart Failure Patients

Background: ACEI has been shown to help decrease mortality, morbidity, rate of re-hospitalization, and to improve symptoms of heart failure (HF). However, the rate of ACEI use for HF patients remain low despite the recommendations made by the ACCF/AHA Task Force in the current 2013 HF guideline. It is important to increase the use of ACEI because of its positive effect on the outcome of HF. In addition, improper charting could skew the number of patients who are actually taking ACEI, making it less than it actually it. Thus, providers should be on the forefront of encouraging ACEI use, especially for HF patients. Purpose: The purpose of this study is to evaluate if heart failure patients, aged 18 and over, in a primary care clinic receive ACEI therapy as recommended by the current 2013 HF guideline written by the American College Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force. Methods: This is a retrospective chart review study that will assess for documentation of ACEI therapy in heart failure patients. Unique medical records meeting the inclusion criteria will be reviewed for: the number of patient encounters within the past year, visit day of the week, age, ethnicity, gender, type of health insurance (Medicare, Medi-Cal, private insurance, and uninsured), select vital signs (systolic blood pressure, diastolic blood pressure, and heart rate), ACEI on current active medication list, generic name of ACEI, dose of ACEI, and frequency of ACEI per day. If the patient does not have an ACEI on the current, active medication list, the chart will be reviewed over the year prior to the patient encounter for documentation of an ACEI on active medication list within the past year, an angiotensin-receptor blocker (ARB) on the patient medication list, a hydralazine/isosorbide combination on the patient medication list, allergy to ACEI, cough due to ACEI, hypotension due to ACEI, angioedema due to ACEI, and documentation of other reason for not being on ACEI. Additionally, a focus group will be held after results are analyzed. The focus group will have result dissemination and questions for discussion with providers. Results: 63 charts were reviewed, and the results showed that only 20.6% of patients were currently taking ACEI for HF. The most common cause of not taking ACEI was due to allergies. Out of the 50 charts that did not have ACEI on the current medication list, 42% did not have any type of documentation on why the patient was not on an ACEI. The focus group found that barriers to utilization of ACEI for HF patients included improper or incomplete documentation by the medical assistants (MAs), medication list not up to date because the MAs did not take the time to go through the list with patients, and patient’s lack of knowledge on the disease process and treatment of HF. Conclusion: Based on the results of the study, proper medication reconciliation by the patient and MAs could help to improve documentation and improve the number of actual ACEI use. Decreasing patient load could help improve quality of patient and increase patient satisfaction. This will increase patient involvement in the treatment plan, thus increasing rate of adherence to ACEI. Lastly, continuous guideline education will encourage provider to use evidence-based therapies to treat HF

Perceived barriers of heart failure nurses and cardiologists in using clinical decision support systems in the treatment of heart failure patients

<p>Background: Clinical Decision Support Systems (CDSSs) can support guideline adherence in heart failure (HF) patients. However, the use of CDSSs is limited and barriers in working with CDSSs have been described as a major obstacle. It is unknown if barriers to CDSSs are present and differ between HF nurses and cardiologists. Therefore the aims of this study are; 1. Explore the type and number of perceived barriers of HF nurses and cardiologists to use a CDSS in the treatment of HF patients. 2. Explore possible differences in perceived barriers between two groups. 3. Assess the relevance and influence of knowledge management (KM) on Responsibility/Trust (R&T) and Barriers/Threats (B&T).</p><p>Methods: A questionnaire was developed including; B&T, R&T, and KM. For analyses, descriptive techniques, 2-tailed Pearson correlation tests, and multiple regression analyses were performed.</p><p>Results: The response-rate of 220 questionnaires was 74%. Barriers were found for cardiologists and HF nurses in all the constructs. Sixty-five percent did not want to be dependent on a CDSS. Nevertheless thirty-six percent of HF nurses and 50% of cardiologists stated that a CDSS can optimize HF medication. No relationship between constructs and age; gender; years of work experience; general computer experience and email/internet were observed. In the group of HF nurses a positive correlation (r .33, P</p><p>Conclusions: Both cardiologists and HF-nurses perceived barriers in working with a CDSS in all of the examined constructs. KM has a strong positive correlation with perceived barriers, indicating that increasing knowledge about CDSSs can decrease their barriers.</p>

Mode of transport to hospital among patients with ST Elevation Acute Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi: correlates, physician and patient attitudes, and associated clinical outcomes

Introduction: Acute coronary syndromes, including ST-elevation myocardial infarction (STEMI), are a leading cause of morbidity and mortality worldwide. Existing research shows that prehospital care provided by emergency medical services (EMS) can significantly improve outcomes. However, EMS remains grossly underutilised in Abu Dhabi despite a well-established presence. Objectives: In this three-part quantitative, observational study, we sought to (1) assess physicians' perceptions of, and recommendations for, utilization and improvement of EMS, (2) assess patients' awareness of EMS, mode of transport use in decision to seek care and reasons for their decision, and (3) establish if in the current study setting, mode of transport used has implications for in hospital adverse events, as well as short and long term clinical outcomes. The goal was to investigate both physicians' and patients' perceptions of prehospital STEMI care, as well as to assess the clinical correlates of the mode of transport in a patient's decision to seek care. Methods: We conducted the study in three phases. Phase 1: At four government-operated hospitals in Abu Dhabi, we administered surveys to a convenience sample of physicians involved in care of patients with acute coronary syndromes to measure (a) likelihood of recommending EMS, (b) satisfaction with EMS, (c) likelihood of using EMS for self or family, and (d) recommendations for prehospital care of acute coronary syndromes. Phase 2: We gathered mode of transport data from a purposive, non-random sample of 587 consecutive patients with STEMI over an 18-month period and conducted structured follow-up interviews to assess their perceptions of EMS. We conducted analysis to determine whether mode of transport was related to demographic variables. Phase 3: We collected medical records from patient participants and conducted structured follow-up interviews at 1, 6 and 12 months post discharge. We conducted chi square difference testing to determine the relationships among mode of transport, treatment times, and short- and long-term clinical outcomes. Variables included treatment times and associated outcomes. Results: Physician participants (n = 106) were most supportive of prehospital 12-lead ECG for STEMI, but indicated low satisfaction with existing EMS services in Abu Dhabi. Among STEMI patient participants (n = 587), EMS was underutilized in Abu Dhabi; over half (55%) of patients did not know the phone number to contact EMS, and only 14.7% used EMS in their decision to seek care. EMS-transported patients were more likely to receive timely treatment (door-todiagnostic ECG time, door-to-balloon time) and had lower incidence of mortality compared to privately-transported patients. Conclusions: These findings suggest a need to raise public awareness of EMS and its importance for coronary symptoms in Abu Dhabi. Broader application of prehospital ECG, including prehospital activation of cardiac catheterization labs, bypassing non-interventional cardiology centres, and admission directly to facilities that provide these services without initial admission to the emergency department, could help improve physicians' perceptions of EMS and outcomes for patients with STEMI

Self-care behaviour in terms of compliance and delay of patients with heart failure

Therapieontrouw met medicatie en leefregels (natriumarm dieet, vochtbeperking, dagelijks wegen om te controleren op het vasthouden van vocht en bewegen) heeft een ongunstig effect op prognose van patiënten met hartfalen. Verder is het ook niet goed dat patiënten lang wachten met het inschakelen van hulp bij verergering van symptomen (‘delay’). Dit onderzoek beschrijft verschillende variabelen en kenmerken van patiënten met hartfalen die verband houden met therapietrouw en delay. Hiertoe is data uit COACH (Coordinating study evaluating Outcomes on Advising and Counselling in Heart failure) benut. De complexiteit van de voorschriften bleek een bepalende factor ten aanzien van therapietrouw met medicatie, dieet, en vochtbeperking. Therapietrouw met dagelijks wegen en bewegen was op lange termijn lager dan therapietrouw met dieet en vochtbeperking. Kennis over hartfalen en voorlichting verbeterden therapietrouw met dieet en wegen, maar hadden geen effect op therapietrouw met bewegen. Ouderdom, comorbiditeit, en motivatie (het ervaren van plezier of het inzien van het belang van bewegen) waren bepalende factoren bij therapietrouw met bewegen. Patiënten met hartfalen wachten vaak lang met het inschakelen van hulp na verergering van symptomen, zelfs als ze al eens eerder zijn opgenomen voor hartfalen. Wel schakelden patiënten die een andere levensbedreigende ziekte hadden meegemaakt (hartinfarct of beroerte) eerder een hulpverlener in vergeleken met de rest van de patiëntenpopulatie. Ook bleken patiënten met depressieve klachten langer te wachten met het inschakelen van een hulpverlener. De door dit onderzoek ontdekte nieuwe inzichten zijn van belang bij het geven van adviezen ‘op maat’ om de zelfzorg van patiënten met hartfalen te verbeteren