Clinical decision guidelines for NHS cosmetic surgery: analysis of current limitations and recommendations for future development.

Because of increasing demand for publicly funded elective cosmetic surgery, clinical decision guidelines have been developed to select those patients who should receive it. The aims of this study were to identify: the main characteristics of such guidelines; whether and how they influence clinical decision making; and ways in which they should be improved. UK health authorities were asked for their current guidelines for elective cosmetic surgery and, in a single plastic surgery unit, we examined the impact of its guidelines by observing consultations and interviewing surgeons and managers. Of 115 authorities approached, 32 reported using guidelines and provided sufficient information for analysis. Guidelines mostly concerned arbitrary sets of cosmetic procedures and lacked reference to an evidence base. They allowed surgery for specified anatomical, functional or symptomatic reasons, but these indications varied between guidelines. Most guidelines also permitted surgery 'exceptionally' for psychological reasons. The guidelines that were studied in detail did not appreciably influence surgeons' decisions, which reflected criteria that were not cited in the guidelines, including cost of the procedure and whether patients sought restoration or improvement of their appearance. Decision guidelines in this area have several limitations. Future guidelines should: include all cosmetic procedures; be informed by a broad range of evidence; and, arguably, include several nonclinical criteria that currently inform surgeons' decision-making.     

Hand hygiene: an evidence-based review for surgeons

This review of the literature discusses the scientific evidence behind using different hand hygiene agents on the surgical ward, and in theatre for preoperative disinfection. It considers the mechanism of action of the agents and their effectiveness against different pathogens, as well as possible future agents, and how they are tested. It addresses problems such as the poor compliance with hand hygiene guidelines by healthcare workers (especially doctors) and investigates what can be done to improve compliance. Finally, it demonstrates the reduction in hospital acquired infection (HAI) rate that can be achieved by improving hand hygiene compliance, and shows that the savings associated with this easily outweigh the cost.     

Donor families, distinctive secondary losses, and "second death" experiences

Communication between donor families and the recipients of their loved ones' organs and tissues is a relatively new area of study. The National Kidney Foundation founded the National Donor Family Council in 1992 as a home for donor families. One of several items addressed by the Council was guidelines for communication, supporting the rights of donor families and recipients to communicate and build relationships should they choose to do so. Donation and transplant agencies play a strong role in facilitating and supporting donor families and recipients with these unique new relationships. This article offers 3 case examples of distinctive secondary losses and "second death" experiences encountered by some donor family members when the donation of tissues or organs they have authorized could not be used for transplantation, when those grafts fail or are rejected, or when the recipient dies. On that basis, the article explores the nature of these experiences and some reasons why they occur. Initial recommendations about how to address these experiences are provided. Finally, a 4-part agenda is suggested for research about (1) the nature of these distinctive secondary loss and second death experiences encountered by some donor families; (2) communications between donation and transplant professionals, on the one hand, and potential and actual donor family members, on the other hand; (3) the education, training, and support of professionals who provide bereavement support to donor family members; and (4) a review of the National Communication Guidelines.     

Antibioprophylaxy in hand surgery: toward a professional consensus

Antibioprophylaxy in surgery follows, in France, the guidelines published by the French Society of Anesthesia [Société fran?aise d'Anesthésie et reanimation (SFAR)]. However these guidelines were mostly made for prosthetic and traumatologic surgery of the lower limb and guidelines for upper limb and hand surgery have been made by extrapolation. The French Society for Surgery of the hand has made multiples studies including: a survey to precise the infection rate for hand surgery which has been estimated to be around 0.1%. A search in the international literature, according to the classification criteria proposed by the "Agence Nationale D'accréditation et d'Evaluation Sanitaire (ANAES)" to better define correct antibioprophylaxy that should be used in hand surgery. Results of those surveys have been presented by national experts at the French Society Meeting of 2003. The attendance was given the opportunity to answer questions from the experts. A jury was present and its conclusion are reported here. Except for total wrist prosthesis and for surgical procedures that last more than 2 hours, there are very few indications for an antibioprophylaxy in hand surgery. In cases where an antibioprophylaxy is needed, the jury recommends that the guidelines proposed by the SFAR, regarding the choice of antibiotics, should be followed.     

Quality assurance that will ensure robust and transparent guidelines

The AGREE collaboration provides minimum quality standards for guidelines, yet none of the current wound-care guidelines acknowledge whether they fulfil these criteria. Only guidelines that comply with AGREE are likely to improve practice.     

The introduction of laparoscopic cholecystectomy to Australia and New Zealand: an illustration of establishing training and standards for new clinical privileges

The introduction of new technology or procedures raises the issues: who should do it and use it? what training should they have? where should it be performed? what cases are appropriate? and how is outcome evaluated and who does the evaluation? The problem is well illustrated by laparoscopic cholecystectomy, which in Australia and New Zealand unlike other countries, was introduced within the College of Surgeons. The College's responsibility was to assess and then disseminate the new procedure to the community by training surgeons, yet at the same time minimize the risk to the community. The College defined criteria for performing laparoscopic cholecystectomy, facilitated workshops and defined how they should be organized, carried out a national audit of laparoscopic cholecystectomy and has subsequently set criteria for the introduction of advanced and other minimal access techniques. With the College delineating guidelines, individual institutions then had the responsibility of credentialling their surgeons. As it is impractical to credential for each individual procedure, the solution is to credential groups' procedures. Equivalent procedures are those in which what is achieved laparoscopically is the same as open, e.g. cholecystectomy (provided intraoperative cholangiography is still used). Alternate procedures are those in which the laparoscopic procedure is changed from the open procedure or the outcome is uncertain, e.g. bowel resection. These procedures should be limited to those undertaking them within an institutional trial or audit. Indifferent procedures are those in which existing surgical principles are not followed, e.g. laparoscopic inguinal hernia repair. These procedures should only be performed in a controlled clinical trial. New techniques and procedures can be introduced safely provided guidelines are established by the Colleges for institutions to act on. Audit by both is essential.     

Excluding patients from transplant due to social support: Results from a national survey of transplant providers

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%‐12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.     

Ethical requirements that must be met before the introduction of new procedures

For orthopaedic care of patients to continue to improve, new approaches, both diagnostic and therapeutic, must be continually developed. To verify that a new approach actually provides improved outcomes, these innovations must be subjected to rigorous scientific study. However, because outcomes of clinical interventions only can be studied in human subjects, these studies must not only meet scientific criteria, they also must meet strict ethical criteria. The Declaration of Helsinki, a document prepared by the World Medical Association that originally was written in 1964, revised substantially in 1975, and most recently revised in 1996, provides guidelines for such studies. In addition to satisfying ethical requirements, clinical investigators also face various complex issues that must be dealt with in the performance of clinical research studies. One of the most difficult issues is the conflict between a physician's concern for the well-being of his or her patients and the need for protocol driven trials. No matter how enthusiastic surgeons may be about a new therapeutic approach, they must recognize that they are responsible to scientifically validate their innovative approach with a well controlled clinical trial using valid functional outcome measures.     

Brief review: History, concept and controversies in the neurological determination of death

PURPOSE: Despite general worldwide acceptance of the concept of neurological determination of death (NDD), inconsistencies in clinical criteria and ancillary testing requirements remain. Numerous guidelines for NDD may be applied in clinical practice by a variety of medical practitioners, but the scientific rationale for specific guideline recommendations often remains unclear. This review examines the evolution of NDD, and seeks to provide scientific validation for existing NDD criteria. SOURCE: English language peer-reviewed medical journals and established contemporary medical texts. PRINCIPAL FINDINGS: Currently published guidelines appear to have evolved from the work of the ad hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. The Conference of the Royal Colleges and Faculties of the United Kingdom refined the criteria and subsequently adopted the principal of brainstem death. While the fundamentals of NDD guidelines are remarkably consistent worldwide, specific criteria and requirements are often inconsistent. CONCLUSION: Numerous controversies regarding NDD continue to exist, necessitating further scientific clarification of these issues. More recently published guidelines representing the collective opinion of world experts in NDD based upon best current scientific evidence are available in current medical journals.     

Practice guidelines and liability implications

It should be clear that the authors of this article are not enamored of practice guidelines, thinking them of much more potential harm than good. On the other hand, if practice guidelines are deemed essential, then they must be written with the goal of quality patient care advocacy and with an eye toward the possible damage they may do.     

Vascular Access Surveillance: Case Study of a False Paradigm

The hemodialysis vascular access surveillance controversy provides a case study of how enthusiasm for a new test or treatment can lead to adoption of a false paradigm. Paradigms are the beliefs and assumptions shared by those in a field of knowledge, and are commonly included in clinical practice guidelines. The guidelines of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommend that arteriovenous vascular accesses undergo routine surveillance for detection and correction of stenosis. This recommendation is based on the paradigm that surveillance of access blood flow or dialysis venous pressure combined with correction of stenosis improves access outcomes. However, the quality of evidence that supports this paradigm has been widely criticized. We tested the validity of the surveillance paradigm by applying World Health Organization (WHO) criteria for evaluating screening tests to a literature review of published vascular access studies. These criteria include four components: undesired condition, screening test, intervention, and desired outcome. The WHO criteria show that surveillance as currently practiced fails all four components and provides little or no significant benefit, suggesting that surveillance is a false paradigm. Once a paradigm is established, however, challenges to its validity are usually resisted even as new evidence indicates the paradigm is not valid. Thus, it is paramount to apply rigorous criteria when developing guidelines. Regulators may help promote needed changes in paradigms when cost and safety considerations coincide.     

Patient selection for day case surgery

Day surgery provides many benefits to patients and trusts. Currently, almost all surgery should be performed as day case or very short stay and as such the criteria for suitability for day case surgery have been much expanded over recent decades. Social and medical criteria should rarely prevent successful day case surgery; we present suggestions whereby historic barriers to discharge can be overcome. We discuss the suitability of surgical procedures to be performed as a day case and explain how emergency pathways can be utilised to enable an additional cohort of patients be treated as a day case. These suggestions will permit the vast majority of patients to reap the benefits of undergoing their procedure as a day case.     

Ergonomic design criteria for a novel laparoscopic tool handle with tactile feedback

Laparoscopic surgery has many ergonomic disadvantages often not considered in the design of instruments. The poorly designed surgical tools produce inconveniences in both functional and cognitive aspects; including tactile sensation and visual-motor space coordination. The aim of this article is to find out how laparoscopic handle design can be improved by combining classical ergonomic guidelines with tactile feedback related to handle design. The article briefly discusses how the human hand and hand-held tools are used to perform tasks. An ergonomic handle for laparoscopic grasping, with a built-in tactile sensation display, is presented. Our review of laparoscopic instruments reveals important aspects for handle design. It is concluded that there is a need for greater awareness of ergonomic guidelines for users' sensory requirements when designing and manufacturing laparoscopic instruments.     

Evaluation of infrastructure, equipment and training of 28 burn units/burn centers in Germany, Austria and Switzerland

Treatment of burn patients requires special training and skills, and an adequate infrastructure. In the United States, burn center referral criteria and requirements of burn centers are defined by the American Burn Association (ABA) in the Guidelines for the Operation of Burn Centers, and in Germany, by the German Society for Burn Treatment (DGV). The European Burn centers in Austria and the German-speaking part of Switzerland share the standards in the setting of the German-speaking Association for Burn Therapy (DAV) with some modifications. The aim of this study was to evaluate the current infrastructure of burn centers in the three German-speaking countries with respect to the existing guidelines. Therefore, guidelines for burn center referral criteria and burn center requirements were compared between the USA (ABA) and Germany (DGV). In addition, a questionnaire was sent to all burn centers in Germany, Austria and the German-speaking part of Switzerland, in order to collect current information regarding the architectural and medical infrastructure, available equipment and care-providing personnel. The comparison of guidelines for the USA and Germany revealed similar burn center referral criteria for both countries. With respect to burn center requirements, both the USA and Germany have similar requirements, albeit with different focus points. In Germany, the main focus lies on the infrastructural requirements for burn centers, while in the US, the main focus lies on the requirements for medical and nursing personnel. Critical review of the responses from the burn centers of German-speaking countries revealed that the biggest infrastructural differences among centers were observed in burn units providing pediatric care, as compared to adult burn centers. In summary, the DGV guidelines for German-speaking countries reflect an overall adoption of the ABA guidelines, and the burn centers included in this study met those requirements. As a result of the positive experience and effective treatment of burn patients in German-speaking countries, we recommend an adoption of the ABA guidelines to those countries and societies that are in need of appropriate standards of burn care.     

Guidelines for the referral and management of patients eligible for solid organ transplantation

Members of the Clinical Practice Committee, American Society of Transplantation, have attempted to define referral criteria for solid organ transplantation. Work done by the Clinical Practice Committee does not represent the official position of the American Society of Transplantation. Recipients for solid organ transplantation are growing in numbers, progressively outstripping the availability of organ donors. As there may be discrepancies in referral practice and, therefore, inequity may exist in terms of access to transplantation, there needs to be uniformity about who should be referred to transplant centers so the system is fair for all patients. A review of the literature that is both generic and organ specific has been conducted so referring physicians can understand the criteria that make the patient a suitable potential transplant candidate. The psychosocial milieu that needs to be addressed is part of the transplant evaluation. Early intervention and evaluation appear to play a positive role in maximizing quality of life for the transplant recipient. There is evidence, especially in nephrology, that the majority of patients with progressive failure are referred to transplant centers at a late stage of disease. Evidence-based medicine forms the basis for medical decision-making about accepting the patient as a transplant candidate. The exact criteria for each organ are detailed. These guidelines reflect consensus opinions, synthesized by the authors after extensive literature review and reflecting the experience at their major transplant centers. These guidelines can be distributed by transplant centers to referring physicians, to aid them in understanding who is potentially an acceptable candidate for transplantation. The more familiar physicians are with the exact criteria for specific organ transplantation, the more likely they are to refer patients at an appropriate stage. Individual transplant centers will make final decisions on acceptability for transplantation based on specific patient factors. It is hoped that this overview will assist insurers/payors in reimbursing transplant centers for solid organ transplantation, based on criteria for acceptability by the transplant community. The selection and management of patients with end-stage organ failure are constantly changing, and future advances may make obsolete some of the criteria mentioned in the guidelines. Most importantly, these are intended to be guidelines, not rules.     

Casting, splinting, and physical and occupational therapy of hand deformity and dysfunction in cerebral palsy

The treatment of hand deformity and associated dysfunction is a major focus of physical and occupational therapy for people with CP, as poor grasp and manipulation has potential to impact on many aspects of daily life. To assist therapists in analyzing patterns of movement of the wrist, finger, and thumb musculature at rest and during functional activities, five patterns of deformity commonly seen in the hypertonic hand are described. Interventions that impact on hypertonicity and associated contracture and that facilitate functional use of the hand in the presence of these deformities are discussed. The paucity of evidence from clinical trials on intervention strategies reflects in part the diversity of people with CP and the highly individual functional problems they encounter. While further research is needed on the many possible interventions and how they contribute to maximizing hand function, there is increasing evidence of the value of therapy that is directed to functional outcomes relevant to the individual.     

Previous experiences with evaluation of practice guidelines

Numerous expectations are associated with the development of guidelines. Referring to the experiences so far it can be stated that despite the large amount of guidelines that have been developed, little attention has been given to dissemination, implementation and evaluation of guidelines. The developed guidelines often do not follow international accepted quality criteria, for example many are not based on scientific evidence or they lack the involvement of all relevant parties. The main problems occur in the process from development to implementation of a guideline. Results from evaluation studies nevertheless show that guidelines can have positive effects on the process and outcome of medical care. More scientifically sound evaluation studies are needed to assess the effects of guidelines. Especially in Germany a lot more needs to be done to improve the quality of guidelines and the amount of evaluation studies.     

How do therapists administer the rapid exchange grip test? A survey.

The rapid exchange grip (REG) test is one of many methods devised to detect insincere grip strength efforts. Studies investigating the REG test have used different testing protocols and different interpretation criteria for what constitutes a sincere effort. Since therapists get information about evaluation tools from the literature, inconsistencies among researchers may lead to a lack of standardization in the administration of the REG test among therapists. The purpose of the study was to survey therapists to determine what protocol they follow during REG test administration and how they interpret the REG test results. Fourteen therapists working in hand clinics completed the survey. The ways in which the therapists administered the REG test varied widely. Differences among therapists in administering the REG test included the position of the patient, the handling of the dynamometer, the number of repetitions, the hand switch rate, and the comparative test used to interpret the REG test. On the basis of these results, we concluded that the REG test does not meet the most basic testing and measurement criteria. This may impede the ability of therapists to report the outcomes of the REG test accurately and correctly. The implications for the profession due to the lack of standardization of the REG test are discussed.     

Access to hand surgery emergency care

Limited access to hand surgical care in the emergency room appears to be a problem in north Florida and probably other parts of the country, as well. In this study, hand surgeons in 3 major cities were contacted to determine what on-call services they provide for hospital emergency departments in their areas. Additionally, hospitals that accept trauma patients were queried about how many hand surgeons they have on staff and if there were times when no surgeon was on call and how they managed hand trauma when that problem is encountered. Results showed that although there are numerous hand surgeons in each city, there were many times in which a hospital would have no hand surgeon on call for an emergency. Our data suggest that on a regionally selective basis, hospital emergency facilities are deficient with respect to the availability of appropriate specialists for those patients requiring emergency hand procedures.