Entscheidend ist, was ankommt

Background

Guidelines are developed to improve the quality of patient care. The effect of German urologic guidelines has not been evaluated so far. Therefore, we aimed to systematically investigate the acceptance, use, and quality of the published guidelines from a user’s perspective.

Methods

A link to an online questionnaire concerning use and barriers to the application of guidelines was distributed via e-mail by the German Society of Urology (DGU). German urologists’ opinions on differences in national guideline quality were evaluated regarding prostate cancer (PCA), bladder cancer, germ cell tumors (GCT), renal cell carcinomas, and erectile dysfunction.

Results

Four hundred sixty-seven German urologists participated. More than 90% of the participants considered guidelines to be helpful. The Internet as the main tool for guideline distribution was favored by 28.4%, followed by publication in Urologe A. The main barrier to guideline usage was attributed to the lack of up-to date clinical data. Guidelines for GCT scored best in all quality categories and reached the highest level of use (65.8%), and 40.5% of participating urologists considered the additional establishment of comprehensive care centers for GCT as more effective for quality improvement than guideline development alone. For the other urologic tumors, especially PCA, guideline development was favored as a tool for quality improvement.

Conclusion

More than 90% of participating urologists accept clinical guidelines as useful instruments in clinical practice and for therapeutic decisions. Our results should be integrated into guideline dissemination and implementation strategies in order to achieve a higher degree of treatment conformation to guidelines.     

Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children after trauma

Introduction

Venous thromboembolism (VTE) is increasingly prevalent in injured children admitted to the intensive care unit (ICU). Few data exist to support VTE pharmacologic prophylaxis or ultrasound (US) surveillance in children with high bleeding risk. After implementation of screening US guidelines, we sought to describe our experience, hypothesizing that screening US of children at highest risk for VTE results in earlier detection and management.

Antibiotikaprophylaxe bei transurethraler Resektion der Prostata (TUR-P)

Background

For patients undergoing urologic interventions, relevant aspects of antibiotic prophylaxis such as drug of choice and duration of prophylaxis are still discussed controversially. According to the current European and German guidelines, single-shot prophylaxis is recommended only in patients with risk factors.

Methods

Discussion of two published meta-analyses with regard to of recently published randomized controlled trials.

Results

Two comprehensive meta-analyses concordantly revealed a significant reduction in bacteriuria and fever incidence without stratification according to preexisting risk factors. A single antibiotic dose (“single shot”) of, for example, a cephalosporin or chinolone reduced the bacteriuria rate significantly. However, for the cephalosporines, the most frequently studied drug class, repeated dosing seems to be more effective.

Conclusion

Antibiotic prophylaxis reduces the rates of bacteriuria and fever in patients without existing risk factors undergoing transurethral resection of the prostate. The optimal duration of antibiotic prophylaxis and the drug of choice must be evaluated in further studies investigating clinically relevant endpoints.     

Pancreatoduodenectomy—current status of surgical and perioperative techniques in Germany

Background

Pancreatoduodenectomy in Germany is performed by a broad range of hospitals. A diversity of operative techniques is employed as no guidelines exist for intra- and perioperative management. We carried out a national survey to determine the de facto German standards for pancreatoduodenectomy, assess quality assurance measures, and identify relevant issues for further investigation.

Methods

A questionnaire evaluating major outcome variables, case load, preferred surgical procedures, and perioperative management during pancreatoduodenectomy was developed and sent to 211 German hospitals performing >12 pancreatoduodenectomies per year (requirement for certification as a pancreas center). Statistical analysis was carried out using the Fisher Exact, Mann–Whitney U, and Spearman tests.

Results

The final response rate was 86 % (182/211). The preferred technique and de facto German standard for pancreatoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreatojejunostomy carried out via duct-to-mucosa anastomosis with interrupted sutures using PDS 4.0. The minority of German pancreas centers were certified (18–48 %). The certification rate increased with higher capacity levels and case load (P?<?0.05); however, significant correlations between the fistula rate and hospital case load, hospital capacity level, or hospital certification status were not seen.

Conclusion

This study revealed a distinct variety of management strategies for pancreatic surgery and available evidence-based data was not necessarily translated into clinical practice. The limited certification rate represented a shortcoming of quality assurance. The data emphasize the need for further trials to answer the questions whether hospital certifications and omission of drains improve outcome after pancreatoduodenectomy and for the establishment of guidelines for pancreatoduodenectomy.     

What is the utilization of the SAGES guidelines by its members?

Background

The development and implementation of evidence-based clinical practice guidelines involves many challenges. The Society of the American Gastrointestinal and Endoscopic Surgeons (SAGES) has been at the forefront of guideline development for laparoscopic surgery since 1991, providing its membership with guidelines on the clinical application of procedures and the granting of privileges. The objective of this study was to assess the use of SAGES guidelines by its members.

Methods

An electronic survey of SAGES members was conducted via e-mail in August 2007. Members were asked if they used the guidelines, how often, for what purposes and when, and to rank the frequency of use and the usefulness of each of the 26 guidelines. They also were asked to suggest topics for new guideline development and to provide comments.

Results

Two hundred thirty-nine SAGES members (4.1%) responded to the survey; 121 (50%) responders used the guidelines. Of these, 95% accessed the guidelines monthly or less often, 58% after hours, 52% during work hours, and 9% while on call. Reasons for guideline use included developing practice protocols (56%) and patient treatment paradigms (51%), creating education and training guidelines for staff privileges (35%), and credentialing new medical staff (25%). The most often used and most useful guidelines included clinical application guidelines on laparoscopic bariatric, antireflux, biliary, and colorectal surgery, laparoscopic appendectomy, and deep vein thrombosis prophylaxis. Some respondents indicated no knowledge of guideline existence and made requests for new guidelines.

Conclusions

The results of this survey provided valuable information about current use of SAGES guidelines by its members. The pattern of use highlights the need for interventions that increase member awareness and adoption of these guidelines. Such efforts are currently underway.     

How do SAGES members rate its guidelines?

Background

The development of practice guidelines should take into consideration the opinions of end users. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has implemented several changes in its guideline development and dissemination process based on previous end-user input.

Methods

An anonymous electronic survey was conducted via e-mail solicitation in September 2011. Respondents were asked to submit their feedback on the 26 guidelines produced by our society using a 32-item questionnaire and to suggest topics for new guideline development and areas of improvement.

Results

Responses from the survey were received by 494 people, of whom 474 (96 %) were clinicians; 373 (75 %) were general, laparoscopic, or bariatric surgeons; and 324 (65 %) held leadership roles within their institution. Most respondents were 35–44 years old (36 %), male (83 %), and had been in practice for over 10 years (54 %). A total of 383 (81 %) had used our guidelines, and, of those, 96 % agreed with their content. Guideline quality was rated 4.34; value 4.27; and ease of access 3.97 on a five-point Likert scale. The most commonly referenced guideline in the survey regarded surgical treatment of reflux (67 %), followed by laparoscopy during pregnancy (51 %). The three most common reasons guidelines were accessed were to update knowledge (68 %), to maximize patient care through evidence-based treatment (51 %), and to obtain a critical literature review.

Conclusions

The majority of respondents indicated they greatly value and agree with our guidelines. These results indicate that recent efforts to improve our guidelines have succeeded.     

Venous thromboembolism after laparoscopic cholecystectomy: clinical burden and prevention

Background

The clinical benefit of prophylaxis for venous thromboembolism (VTE) in laparoscopic cholecystectomy is unclear. This study aimed to assess the clinical burden of VTE and the efficacy and safety of antithrombotic prophylaxis during laparoscopic cholecystectomy.

Methods

Data sources and study selection studies were searched in MEDLINE and Embase using the terms “cholecystectomy and venous thrombosis” and “cholecystectomy and venous thromboembolism.” Studies were considered for a systematic review and a metaanalysis if they reported on the methods of antithrombotic prophylaxis and on the incidence of objectively confirmed VTE in patients who had undergone laparoscopic cholecystectomy. Overall, 15 studies of patients who had undergone laparoscopic cholecystectomy were included in the systematic review.

Results

The incidence of VTE was lower after laparoscopic cholecystectomy than after open cholecystectomy [odds ratio (OR), 0.47; 95 % confidence interval (CI), 0.40–0.56]. No statistically significant reduction in VTE was observed in patients receiving heparin prophylaxis after laparoscopic cholecystectomy (OR, 0.86; 95 % CI, 0.12–5.82).

Conclusions

The rate of VTE after laparoscopic cholecystectomy seems to be relatively low. The clinical benefit of heparin prophylaxis for patients undergoing laparoscopic cholecystectomy remains unclear.     

Indikationsstellung in der primären Hüft- und Kniegelenkendoprothetik

Background

The German mandatory quality assurance programme collects data from all primary total hip and knee replacements. The quality of the indication is measured by clinical and radiological criteria. The results were analysed in terms of differences in establishing the indication subject to patient and hospital characteristics.

Materials and methods

Data on more than 270,000 primary total hip and knee replacements that were operated in 2006 in Germany were analysed concerning differences in the quality of the indication subject to age, gender, hospital volume and density of population and hospitals (metropolitan vs rural areas). The statistical analysis was done by exact Fisher’s test.

Results

The quality of the indication was statistically significantly better in men, patients 60 and older, in rural areas and in high volume hospitals (50 and more joint replacements per year).

Discussion

Data of this mandatory German quality assurance programme are useful to describe differences in medical care. The results are valid and complete. An exact analysis of the reasons for these differences is difficult though. Data focus is on quality assurance and represent only in-hospital results.

Conclusion

Further analyses are necessary to ascertain whether the differences in quality of care are deficits or only variances in medical care.     

Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story

Background

The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created due to recognition of the impact of proper perioperative prophylaxis on an estimated annual one million inpatient days and $1.6 billion in excess health care costs secondary to preventable surgical site infections (SSIs). An internal study was conducted to create low cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration.

Methods

We assessed the impact of auditing and notifying providers of SCIP errors on overall compliance with inpatient antibiotic guidelines and on net financial gain or loss to a large tertiary center between March 1st 2010 and September 31st 2013. We hypothesized that direct physician-to-physician feedback would result in significant compliance improvements.

Results

Through physician notification, our hospital was able to significantly improve SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for re-investment in patient care initiatives.

Conclusions

Provider education and direct notification of SCIP prophylactic antibiotic dosing errors resulted in improved compliance with national patient improvement guidelines. There were differences between the anesthesiology and surgery department feedback responses, the latter likely attributed to diverse surgical department sub-divisions, frequent changes in resident trainees and supervising attending staff, and the comparative ability. Provider notification of guideline non-compliance should be encouraged as standard practice to improve patient safety. Also, the hospital experienced increased revenue for re-investment in patient care as a secondary result of provider notification.

     

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis

Summary

This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18?years and over in whom oral glucocorticoid therapy is considered for 3?months or longer.

Introduction

The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010.

Methods and results

The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review.

Conclusions

Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.     

Verbessertes Überleben durch leitliniengerechte kardiopulmonale Reanimation

Background

In 2005 revised guidelines for cardiopulmonary resuscitation (CPR) were published by the European Resuscitation Council replacing the guidelines implemented in the year 2000. The aim of this study was to test the compliance with valid guidelines and to establish the quality of pre-hospital CPR provided by paramedics over a period of 38 months.

Patients and methods

A total of 299 CPRs performed by paramedics of the emergency medical services of Hamburg, Germany between 1^st November 2004 and 31^st December 2007 were analyzed. Digital recordings of automated external defibrillators and emergency protocol data were analyzed in detail. CPR was judged as incorrect if the defibrillation energy level did not correspond to the valid guidelines or if the interval between defibrillations exceeded a tolerance range of more than 30% compared to the valid guidelines.

Results

All CPRs (299) were included in the analysis of which 197 (65.9%) were intended to follow the 2000 guidelines and 102 (34.1%) the 2005 guidelines. Return of spontaneous circulation (ROSC) was achieved in 164 cases (54.8%) and survival to hospital admission in 125 cases (41.8%). CPR was performed accurately according to guidelines in only 26 cases (8.7%). In 273 cases (91.3%) the guidelines were not followed completely. Concerning the translation of guidelines into practice most faults occurred due to wrong intervals (89.3%), wrong defibrillation energy (33.4%) and medical errors, such as defibrillating an asystolic patient (7.0%). Primary survival rates were not significantly different when CPR accurately followed the 2000 or 2005 guidelines (40.1% versus 45.1%). Comparing primary survival rates of cases in which the guidelines were followed completely, there was no significant difference between the 2000 guidelines (15 out of 21 cases 71.4%) and 2005 guidelines (4 out of 5 cases 80.0%). However, compliance with valid guidelines significantly increased primary survival rates compared to non-compliance with valid guidelines (19 out of 26 cases 73.1% versus 106 out of 273 cases 38.8%; p=0.007). This effect was independent of the duration of CPR. Comparing CPR with monophasic defibrillation (189 cases) or biphasic defibrillation (58 cases), there was a significantly higher rate of ROSC (56.1% versus 72.4%) and a significantly higher rate of primary survival (41.3% versus 56.9%) in favour of biphasic defibrillation.

Conclusion

The results of our study show that compliance with valid guidelines is low and furthermore suggest that compliance with guidelines significantly reduces mortality. Future research may be warranted into the question of how to increase compliance with current CPR guidelines in pre-hospital emergency care.     

Physikalische Thromboembolieprophylaxe

Background

Thromboprophylaxis in surgery patients is a combination of physical and medical thromboprophylaxis. The established mode of physical thromboprophylaxis in Germany is graduated compression stockings. Recent publications from various authors generally scrutinized the additional benefits of physical prophylaxis in patients who received medical thromboprophylaxis.

Material and methods

A thorough search was carried out in PubMed and Medline. The focus of the search was on studies which investigated the advantages of physical thromboprophylaxis in surgery patients.

Results

The low amount of evidence available for prophylaxis of thromboembolism in surgery patients was mainly deduced from trials that had a combination of medical and physical thromboprophylaxis as part of the study protocol. The results of experimental investigations were able to show a statistically highly significant reduction of the diameter of lower extremity veins.

Conclusion

There is no current evidence to support refraining from routine use of graduated compression stockings in surgery patients. This is also the case for the new oral anti-Xa and anti-IIa inhibitors.     

Prophylaxis of venous thromboembolism in general surgery: guidelines differ and we still need local policies

INTRODUCTION

Venous thromboembolism (VTE) prophylaxis has become a major issue for surgeons both in the UK and worldwide. Sev-eral different sources of guidance on VTE prophylaxis are available but these differ in design and detail.

METHODS

Two similar audits were performed, one year apart, on the VTE prophylaxis prescribed for all general surgical inpatients during a single week (90 patients and 101 patients). Classification of patients into different risk groups and compliance in prescribing prophylaxis were examined using different international, national and local guidelines.

RESULTS

There were significant differences between the numbers of patients in high, moderate and low-risk groups according to the different guidelines. When groups were combined to indicate simply ‘at risk’ or ‘not at risk’ (in the manner of one of the guidelines), then differences were not significant. Our compliance improved from the first audit to the second. Patients at high risk received VTE prophylaxis according to guidance more consistently than those at low risk.

CONCLUSIONS

Differences in guidance on VTE prophylaxis can affect compliance significantly when auditing practice, depending on the choice of ‘gold standard’. National guidance does not remove the need for clear and detailed local policies. Making decisions about policies for lower-risk patients can be more difficult than for those at high risk.     

Clinical characteristics and risk factors for septic shock in patients receiving emergency drainage for acute pyelonephritis with upper urinary tract calculi

Background

Guideline recommendations on therapy in urinary tract infections are based on antibiotic resistance rates. Due to a lack of surveillance data, little is known about resistance rates in uncomplicated urinary tract infection (UTI) in general practice in Germany. In a prospective observational study, urine cultures of all women presenting with urinary tract infections in general practice were analysed. Resistance rates against antibiotics recommended in German guidelines on UTI are presented.

Methods

In a prospective, multi-center observational study general practitioner included all female patients?≥?18 years with clinically suspected urinary tract infection. Only patients receiving an antibiotic therapy within the last two weeks were excluded.

Results

40 practices recruited 191 female patients (mean age 52 years; range 18–96) with urinary tract infections. Main causative agent was Escherichia coli (79%) followed by Enterococcus faecalis (14%) and Klebsiella pneumoniae (7.3%). Susceptibiliy of E.coli as the main causative agent was highest against fosfomycin and nitrofurantoin, with low resistance rates of 4,5%; 2,2%. In 17,5%, E.coli was resistant to trimethoprim and in 8,5% to ciprofloxacin.

Conclusions

Resistance rates of uropathogens from unselected patients in general practice differ from routinely collected laboratory data. These results can have an impact on antibiotic prescribing and treatment recommendations.     

Comparison of guideline recommendations for antimicrobial prophylaxis in urologic procedures: variability,lack of consensus,and contradictions

Purpose

This review assesses guideline discrepancies for urologic surgery antimicrobial prophylaxis and identifies opportunities for improvement of antimicrobial prophylaxis and stewardship.

Methods

Literature search using PubMed, Embase, Cochrane, and association websites identified guidelines for review from the American Urological Association, Canadian Urological Association, European Association of Urology, Japanese Urological Association, and Association of Health-System Pharmacists/Infectious Disease Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America.

Results

The greatest variability between guidelines was found in prophylaxis recommendations for prostate brachytherapy, transurethral resection of bladder tumor, extracorporeal shock wave lithotripsy (ESWL), and ureteroscopy with manipulation. Variability was also present in recommended duration of prophylaxis and recommended antibiotic. Contradictions between guidelines existed regarding prophylaxis for patients with indwelling stents undergoing ESWL, as well as for patients at risk of endocarditis undergoing urologic procedures. Procedures with the least variability in prophylaxis recommendation included diagnostic procedures (cystourethroscopy, urodynamic studies, and diagnostic ureteroscopy), transurethral resection of prostate, transrectal prostate biopsy, percutaneous nephrolithotomy, procedures involving prosthesis placement or intestine, and open or laparoscopic procedures.

Conclusions

Consensus recommendations are present for several procedures, many of which still rely on non-urologic data. Several other procedures have variability in recommendations, generally due to a lack of strong data. The use of risk factors as indication for prophylaxis in many procedures is at times ambiguous and confusing. Together, these observations indicate a need for further research to provide more robust and consistent guidelines for antimicrobial prophylaxis and stewardship in the field of urology.

     

Aktuelle Leitlinien in der Berufsdermatologie

Background

According to the definition of the German Working Group of Scientific Medical Societies (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften”), guidelines are systematically developed statements reflecting the current standard of medical knowledge to support the clinical decisions of physicians and patients in order to improve health services. They are important tools of quality assurance in the health care system. Physicians are required to provide guideline-oriented diagnosis and treatment according to Medical Society Regulations and the Patients′ Rights Law.

Guidelines in occupational dermatology

In occupational dermatology, several guidelines exist for the prevention, diagnosis, and treatment of severe and/or repeatedly recurring occupational dermatoses, which force a person to leave the job (German BK 5101) or cause occupational skin cancers (squamous cell carcinoma, actinic keratoses, basal cell carcinoma). Knowledge of the guidelines is not only essential for the treating dermatologists, but also for the officers of the Statutory Accidents Insurance. Consequent implementation of these guidelines in the practice of occupational dermatologists improves the quality of health services in this field.     

The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Purpose

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme.

Methods

Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited.

Results

In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37–1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49–1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20–1.68 %) and incidence of PE 1.15 % (95 % CI 0.53–2.48 %).

Conclusions

We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.