Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation.

BACKGROUND: Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. OBJECTIVES: To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. METHODS: Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. RESULTS: Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. CONCLUSIONS: Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.     

Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients

OBJECTIVES: To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). CONCLUSIONS: There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.     

Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients

BackgroundEvidence is limited on nurse staffing in maternity units.PurposeTo estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines.MethodsWe enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence.FindingsOverall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores.Discussion and ConclusionsImportant gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.     

Heterogeneity of physician agreement with recommended therapeutic guidelines for the management of HIV-associated disease

The aims of this study were to assess the degree of heterogeneity in the knowledge of therapeutic management of HIV infection among HIV-experienced physicians in British Columbia, Canada, and to identify associations between physician characteristics and their agreement with contemporary therapeutic guidelines. A self-administered anonymous questionnaire was mailed to 6500 physician members of the British Columbia Medical Association. The questionnaire provided information about demographic and personal characteristics, including sex, age, medical specialization and practice location; level of experience in treating HIV-infected patients; use of HIV testing procedures; use of preventative vaccinations and tests; and preferred approaches to antiretroviral therapy and the prophylaxis and acute treatment of opportunistic infections. We compared physicians' patterns of knowledge with contemporary recommendations. Logistic regression identified associations between physician characteristics and their agreement with contemporary guidelines. A total of 463 HIV-experienced physicians (a high proportion of the HIV-experienced physicians in British Columbia, Canada) responded to the questionnaire. The agreement with contemporary guidelines about HIV testing and preventative vaccinations and tests among responders ranged from 27% to 71%. For antiretroviral therapy, agreement with the guidelines ranged from 12% to 35%. For the prophylaxis and treatment of opportunistic infections, agreement with the guidelines ranged from 11% to 89% (prophylaxis) and from 46% to 91% (treatment). Regression analysis revealed that physicians actively involved in the care of HIV-infected patients were more likely to agree with the guidelines in all areas of patient care. General practitioners were more likely to agree with the guidelines regarding preventative therapies, and male general practitioners under 45 years old were more likely to agree with the guidelines on antiretroviral therapy. Our data confirm that there is substantial heterogeneity in the management of HIV-associated disease, including some deviations from contemporary guidelines. Concordance with contemporary guidelines increased with the physician's level of HIV-related experience. Our results support the idea that adherence to state-of-the-art practices may be responsible, at least in part, for the recently described association between physician experience and improved survival of HIV-infected individuals.     

Physician process and patient outcome measures for diabetes care: relationships to organizational characteristics

BACKGROUND: Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes. PURPOSE: To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes. DESIGN: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. SAMPLE: We sampled 109 Veterans Affairs medical centers (VAMCs). RESULTS: Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients. CONCLUSIONS: Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.     

Characteristics associated with analgesia ordering in the intensive care unit and relationships with outcome

OBJECTIVE: To describe clinical characteristics associated with analgesia utilization in the intensive care unit. DESIGN: A prospective cohort study of adult patients admitted to a medical intensive care unit. SUBJECTS: Four hundred adult patients. SETTING: Twelve-bed medical intensive care unit of an inner-city, university-affiliated hospital. MEASUREMENTS AND MAIN RESULTS: Collected data included demographics, sedation and neuromuscular blocking agents used, mechanical ventilation, hemodynamic monitoring, Therapeutic Intervention Scoring System score, Logistic Organ Dysfunction System (LODS) score, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Hospital outcome was noted. The odds ratio and 95% confidence intervals were determined by using multiple logistic regression analyses. Patients' mean age (+/-sd) was 47.8 +/- 17.1 yrs; 58% were male, 84% African-American. Their APACHE II-predicted hospital mortality rate was 33%. Analgesics were used in 36% of patients. There were no differences in demographics, initial LODS score, APACHE II score, and mechanical ventilation use between patients who did and did not receive analgesics. Multiple logistic regression analysis showed that analgesic use was independently associated with sedation (odds ratio, 2.47; 95% confidence interval, 1.47-4.14), neuromuscular blockade (odds ratio, 4.98; 95% confidence interval, 1.85-13.41), and pulmonary artery flotation catheter utilization (odds ratio, 2.31; 95% confidence interval, 1.27-4.20). The median duration of mechanical ventilation was 5 days for those who received analgesia compared with 2 for those who did not (p =.0001). The median length of stay in the intensive care unit (4 vs. 2, p <.0001) and hospital (11 vs. 7, p <.0001) was higher in patients who received analgesics. There were no significant differences in intensive care unit and hospital mortality rates between patients who did and did not receive analgesics. CONCLUSIONS: Intensive care unit patients for whom analgesics were prescribed have a higher frequency of hemodynamic monitoring and use of sedative and neuromuscular blocking agents, more mechanical ventilation days, and longer intensive care unit and hospital lengths of stay.     

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.     

A Canadian survey of issues in cancer pain management

We report the analysis of a cancer management survey mailed to a representative group of health professionals in 1994. The goals of the study were to gather information on cancer pain treatment practices, and to obtain health professional views on obstacles to ideal pain management. The survey, designed by a working party of pharmacists, nurses and physicians, was distributed to 14,628 physicians. A total of 2,686 physicians responded to the survey, including 39% of medical or radiation oncologists, and 18.19% of physicians who listed their primary interest as Family Medicine. Reflecting the modest emphasis placed on palliative care and cancer pain management in the current Canadian milieu, 67% of physicians rated their past teaching experience as only “fair” or “poor.” Lack of exposure to pain education was reflected in the response to a series of hypothetical case scenarios exploring physician choices in managing severe cancer pain. For example, in the initial management of a cancer patient with severe pain, 50% of physicians would not use a strong opioid in the absence of other contraindications to opioid use. A wide variety of analgesics and non-pharmacologic techniques is available to Canadian physicians to assist patients with pain. Few physicians identified the unavailability of analgesics or analgesic techniques as limiting factors in pain management. We condude that greater emphasis should be placed on pain education in our training programmes. We suggest that further surveys of this type, sponsored by our provincial colleges and medical organizations, can provide feedback which will enhance the adherence by Canadian physicians to published guidelines for pain management.     

Facilitating clinician adherence to guidelines in the intensive care unit: A multicenter, qualitative study

OBJECTIVE: To determine perceived facilitators and barriers to guideline implementation and clinician adherence to guidelines in the intensive care unit (ICU). DESIGN: Multicenter qualitative study in three university-affiliated ICUs in Canada. METHODS: We conducted individual semistructured interviews of 44 ICU clinicians (12 intensivists, two physician directors, 12 nurses, three nurse educators, three nurse managers, nine respiratory therapists, and three respiratory therapist educators). We elicited attitudes and perceptions regarding the facilitators and barriers to adherence to guidelines in the ICU. We transcribed all interviews and analyzed data in duplicate using grounded theory to identify themes and develop a model to describe clinicians' views. MAIN RESULTS: The presence of a culture within the ICU that enabled guideline implementation and clinician adherence to guidelines was considered essential. Central to this culture was an ICU team that believed guidelines would reduce practice variation, help implement research findings at the bedside, and result in a more rapid implementation of best practice. Effective leadership and positive interprofessional team dynamics were deemed requisites for this culture. Important strategies identified by the participants to overcome potential barriers to clinician adherence to guidelines were: the presence of effective leaders to promote adoption of the guideline and its adherence, education tailored to the learning preferences of different professional groups, and repeated educational interventions, reminders, and audit and feedback. Participants suggested that the use of strategies to select and prioritize guidelines, simple guideline formats, and electronic media to implement guidelines may further contribute to successful guideline programs. CONCLUSIONS: Complex ICU practices and unique interprofessional team dynamics influence clinician adherence to guidelines. Initiatives that employ an approach addressing these issues may optimize guideline uptake and adherence. The optimal approach and its effectiveness may be guideline-dependent and requires further study.     

Commentary: Cabanna M et al. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement

Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behaviour. Little is known about the process and factors involved in changing physician practices in response to guidelines. The aim is to review barriers to physician adherence to clinical practice guidelines. We searched the MEDLINE, Educational Resources Information Center and Health STAR databases (January 1966 to January 1998), bibliographies; textbooks on health behaviour or public health and references supplied by experts to find English language article titles that describe barriers to guideline adherence. Of 5658 articles initially identified, we selected 76 published studies describing at least one barrier to adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. One investigator screened titles to identify candidate articles, then two investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes or behaviour. This organization was validated by three additional investigators. The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity (n = 31), agreement (n = 33), self‐efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys [70 (58%) of 120] examined only one type of barrier. Studies on improving physician guideline adherence may not be generalizable because barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach towards improving guideline adherence and a framework for future research. Abstract reprinted from the Journal of the American Medical Association volume 282, Cabanna M et al., ‘Why don’t physicians follow clinical practice guidelines? A framework for improvement.’, pages 1458–1465. © 1999, reproduced with permission from the American Medical Association.     

National survey of the use of sedating drugs, neuromuscular blocking agents, and reversal agents in the intensive care unit

The objectives of this study were to describe the sedative, neuromuscular blocking agents (NMBA) and reversal agents utilized in adult intensive care units across the United States and determine the adherence to American College of Critical Care Medicine and Society of Critical Care Medicine (SCCM) guidelines. In addition, the authors assessed the use of written protocols, criteria used for selecting these agents, and monitoring practices. Questionnaires were mailed to attending physician members of SCCM in the spring of 1998. A cover letter was enclosed that explained the purpose of the survey asking the respondent to forward the questionnaire to a colleague if unable to complete. Four-hundred fifty-seven questionnaires were returned representing 393 different institutions for a response rate of 50.4% (393/780). Respondents were physicians (91.2%) practicing in a community (49.7%) or university teaching hospital (38.3%). The sedative agents used most often were opioids and benzodiazepines for >72 hours, and NMBA utilized were vecuronium and pancuronium for >24 hours. The most often cited indications for sedatives were agitation, anxiety/fear, and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 32.6% used written protocols for sedatives and 46.8% for NMBA. Decisions regarding agent selection were based on clinician preference and experience and agent duration of action. Seventy-eight percent monitored sedative use primarily with the Glasgow Coma Scale and the modified Ramsay score. Monitoring of NMBA was used more frequently (91.3%) with peripheral nerve stimulation. The most common reversal agents used were naloxone and flumazenil for adverse drug effects. While many of the respondents indicated they used morphine and lorazepam for long-term sedation, the majority utilized midazolam and propofol for >24 hours despite the recommendation of SCCM. Vecuronium was prescribed more routinely than pancuronium. The number of institutions utilizing protocols for any of these agents was low; instead, decisions were based on clinician preference.     

Why outcomes measurement must be the basis for the development of clinical guidelines

Three approaches to clinical quality improvement, health care standards, clinical guidelines, and quality improvement research, are differentiated by the quality of the available medical evidence linking health care processes to health care outcomes. The key determinant of Permanente Medical Group physician acceptance and use of a clinical guideline is the belief that solid data links the guideline's advice to improved patient outcomes. Purchasers, government agencies, regulatory organizations, and health plans must understand the difference between health care standards and clinical guidelines. Strict adherence to clinical guidelines should never be the basis for accountability for physicians, medical groups, or organized systems of care.     

Euthanasia and assisted suicide in Dutch hospitals: the role of nurses

Aim. To report a study on the role of nurses in euthanasia and physician‐assisted suicide in hospitals, conducted as part of a wider study on the role of nurses in medical end‐of‐life decisions. Background. Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician‐assisted suicide gave the Dutch Minister for Health reason to commission a study on the role of nurses in medical end‐of‐life decisions in hospitals, homecare and nursing homes. Method. A questionnaire was sent in 2003 to 692 nurses employed in 73 hospital locations. The response suitable for analysis was from 532 (76·9%) nurses. Data were quantitatively analysed using spss version 11.5 for Windows. Results. In almost half of the cases (45·1%), the nurse was the first with whom patients discussed their request for euthanasia or physician‐assisted suicide. Consultations between physicians and nurses quite often took place (78·8%). In several cases (15·4%), nurses themselves administered the euthanatics with or without a physician. It is not self‐evident that hospitals have guidelines concerning euthanasia/physician‐assisted suicide. Conclusions. In the decision‐making process, the consultation between the physician and the nurse needs improvement. In administering the euthanatics, physicians should take responsibility and should not leave these actions to nurses. Guidelines may play an important role to improve the collaboration between physicians and nurses and to prevent procedural, ethical and legal misunderstandings. Relevance to clinical practice. Nurses in clinical practice are often closely involved in the last stage of a person's life. Consequently, they are often confronted with caring for patients requesting euthanasia or physician‐assisted suicide. The results provide relevant information and may help nurses in defining their role in euthanasia and physician‐assisted suicide, especially in case these practices should become legalised.     

Accounting for the sedative and analgesic effects of medication changes during patient participation in clinical research studies: measurement development and application to a sample of institutionalized geriatric patients

BACKGROUND: To date, no system has been published that allows investigators to adjust for the overall sedative and/or analgesic effects of medications, or changes in medications, in clinical trial participants for whom medication use cannot be controlled. This is common in clinical trials of behavioral and complementary/alternative therapies, and in research involving elderly or chronically ill patients for whom ongoing medical care continues during the trial. This paper describes the development, and illustrates the use, of a method we developed to address this issue, in which we generate single continuous variables to represent the daily sedative and analgesic loads of multiple medications. METHODS: Medications for 90 study participants in a clinical trial of a nonpharmacological intervention were abstracted from medication administration records across multiple treatment periods. An expert panel of three academic clinical pharmacists and a geriatrician met to develop a system by which each study medication could be assigned a sedative and analgesic effect rating. RESULTS: The two measures, when applied to data on 90 institutionalized persons with Alzheimer's disease, resulted in variables with moderately skewed distributions that are consistent with the clinical profile of analgesia and sedation use in long-term care populations. The average study participant received 1.89 analgesic medications per day and had a daily analgesic load of 2.96; the corresponding figures for sedation were 2.07 daily medications and an average daily load of 11.41. CONCLUSIONS: A system of classifying the sedative and analgesic effects of non-study medications was created that divides drugs into categories based on the strength of their effects and assigns a rating to express overall sedative and analgesic effects. These variables may be useful in comparing patients and populations, and to control for drug effects in future studies.     

Paralyzed with pain: the need for education

This report surveyed the pharmacologic knowledge of the physician housestaff and intensive care nurses regarding the analgesic and anxiolytic effects of narcotics, benzodiazepines and neuromuscular blockers. The results demonstrated a commonly held misconception that muscular paralysis is a calm and painless state. The authors instituted an educational program stressing the need for analgesic and anxiolytic medications in conjunction with paralytic agents.     

Provider perceptions of barriers to the emergency use of tPA for Acute Ischemic Stroke: A qualitative study

Background

Only 1-3% of ischemic stroke patients receive thrombolytic therapy. Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known. The main objective of this study was to describe barriers to thrombolytic use in acute stroke care.

Methods

Twenty-four hospitals were randomly selected and matched into 12 pairs. Barrier assessment occurred at intervention sites only, and utilized focus groups and structured interviews. A pre-specified taxonomy was employed to characterize barriers. Two investigators independently assigned themes to transcribed responses. Seven facilitators (three emergency physicians, two nurses, and two study coordinators) conducted focus groups and interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators (12), and three others (hospitalists and pharmacist).

Results

The following themes represented the most important external barriers: environmental and patient factors. Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy. The following themes were not substantial barriers: lack of awareness of the existence of acute stroke guidelines, presence of conflicting guidelines, and lack of agreement with the guidelines.

Conclusions

Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines. Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence. Improving self-efficacy in performing guideline concordant care may also be useful.

Trial Registration

ClinicalTrials.gov identifier: NCT00349479