Clinical guidelines online: do they improve compliance?

BACKGROUND: The introduction of intranet services in a district general hospital provided an opportunity to put evidence based national guidelines online to facilitate access and promote application of best practice in acute medical care. This study evaluated the effectiveness of this approach. METHOD: Local guidelines were made available online at ward terminals after they had been distributed in paper form. An interrupted time series design was used to evaluate the impact on compliance with three preselected guidelines, which addressed the management of suspected deep vein thrombosis, upper gastrointestinal bleeding, and stroke. This was supplemented by a qualitative assessment of the views of medical staff. RESULTS: There was a significant increase in the adherence to the guidelines for stroke when they were made available online, but this was not demonstrable for deep vein thrombosis or upper gastrointestinal bleeding. Qualitative interviews with junior medical staff and consultants after the study was completed revealed that there was confusion regarding the application of the guidelines for deep vein thrombosis and little active support from the gastroenterologists for the guidelines for upper gastrointestinal bleeding. The stroke guidelines were actively promoted by their author and widely supported. CONCLUSION: Making guidelines available online will not be effective unless they are actively promoted and represent a consensus view.

Determination of red cell volume in infants needing blood transfusion.

The total circulating red cell volume (RCV) is a better guide to the oxygen-carrying capacity of the blood in the whole circulation than is the haemoglobin concentration (Hb) or haematocrit in a blood sample. Pre- and post-transfusion RCV (and blood volume (BV)) may be determined by flow cytometry by exploiting antigen differences between transfused donor red cells and the recipient's red cells. This paper describes the use of red cell antigen differences of Duffy, Kidd, MN and RhD between donor and recipient. In 20 infants, transfused on 21 occasions, pretransfusion RCV ranged from 12 to 39 mL kg(-1) body weight. Only at one transfusion could no usable donor-recipient antigen differences be exploited. Measurement of RCV, used routinely, may determine the transfusion requirements of sick infants more accurately, with the aim of normalizing RCV and BV--securing euvolaemia--at the end of the transfusion. This may allow a complete correction of the RCV deficiency at the first occasion of transfusion. This approach may reduce donor exposures and also optimize oxygen transport and organ perfusion of the infant undergoing intensive management, perhaps leading ultimately to improved survival rates and fewer long-term complications of neonatal intensive care.

Two-centre evaluation of the Abbott CD3500 blood counter.

The CD3500 blood counter (Abbott Laboratories) is a 33 parameter fully automated blood counter that produces a five part differential count with flagging of leucocyte abnormalities. In this evaluation excellent correlation between CD3500 and Coulter STKR blood counter was found for all red cell and platelet parameters on the 221 samples tested. Studies of carryover, mixing efficiency and precision also gave excellent results. There was a good correlation with manual 400 cell differential counts for neutrophils, lymphocytes, monocytes and eosinophils for the 468 samples compared. Correlation of CD3500 and manual basophil counts was poor. Normal samples stored at 4 degrees C and analysed while cold showed satisfactory stability for WBC, RBC, Hb, MCV and platelets for 48 h and a stable differential for 24 h. Correlation with the differential count produced by the Coulter STKS showed good correlation for neutrophils, lymphocytes, monocytes and eosinophils; correlation with STKS basophils was poor. False positive flagging rate varied between 8.9% (Band and/or IG) and 0.9% (NRBC) depending on the nature of the flag; 5.8% of samples exhibited two or more false positive flags. No significant breakdowns were encountered during the period of the evaluation. The scatterplot displays of laser light scatter produced by the instrument provide an interesting adjunct to conventional morphology.

Flow cytometric determination of pre-transfusion red cell volume in fetuses and neonates requiring transfusion based on RhD+ dilution by transfused D- red cells.

We report a case of feto-maternal haemorrhage and describe a new flow-cytometric method of determining a fetus's or infant's pre-transfusion red cell volume (RCV). We validate this method against an established technique, employing fetal haemoglobin (HbF) dilution, for determining the RCV in fetuses and neonates requiring intravascular transfusion. We discuss advantages and other potential applications of this new method.

Combination chemotherapy including epirubicin for the management of non-Hodgkin's lymphoma.

One hundred patients with untreated non-Hodgkin's lymphoma were entered in a prospective randomized study in South and West Wales designed to assess the value of the anthracycline antibiotic, epirubicin (4'-epidoxorubicin), in their management. Patients with low grade histology and progressive disease were randomized to receive either epirubicin, vincristine and prednisolone (EVP) or cyclophosphamide, vincristine and prednisolone (CVP). The response rate of 81% in patients receiving EVP with complete remission rate of 52% were similar to a response rate of 88% and complete remission rate of 58% for patients receiving CVP. No difference was observed in survival between the two groups. Patients with high grade lymphoma were randomized to receive either cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) or cyclophosphamide, epirubicin, vincristine and prednisolone (CEOP). The response rate was 71% for CHOP and 84% for CEOP. The complete remission rates were 46% for CHOP and 61% for CEOP. The cardiotoxicity of the two anthracyclines were monitored closely in 45 patients using measurements of systolic time intervals. Patients receiving epirubicin tolerated higher dose per course and higher total cumulative dose with less evidence of compromised left ventricular function than patients receiving doxorubicin. Epirubicin is an effective agent when used in combination chemotherapy in both low grade and high grade lymphoma with less toxicity than doxorubicin.

Factor VIII inhibitor and bronchogenic carcinoma.

An inhibitor to procoagulant factor VIII (FVIIIC) developed in a patient three years after palliative resection of a bronchogenic carcinoma. The inhibitor was not active against ristocetin cofactor but possibly had some activity against factor XI. It responded to immunosuppressive therapy. This is apparently the first reported association of carcinoma and factor VIII inhibitor.

An assessment of laparotomy in the management of patients with Hodgkin's disease.

Planned laparotomy and splenectomy has been a safe investigation for sixty patients with clinical Stage I, II or III Hodgkin's disease. Twenty-four of the 60 patients (40%) changed stage and 18 patients had their treatment altered as a consequence of the procedure. Forty-three per cent of patients without a palpably enlarged spleen had unsuspected disease when the organ was examined pathologically, although a false positive spleen was uncommon. Eight of 55 patients (14.5%) had intra-abdominal disease which was not detected by lymphangiography. Intra-abdominal disease occurred with all histological sub-types and was found in two patients who had clinical Stage I disease and lymphocyte predominance in their node histology. Sarcoid-like granulomata were found in ten patients, seven in the spleen, one in the liver and spleen, one in the skin and one in the original node biopsy. In the majority of patients, granulomata were associated with nodular sclerosing or mixed cellular histology. In all ten patients the Hodgkin's disease was suppressed by appropriate chemotherapy and disease has not recurred. No patient has shown any clinical evidence of sarcoidosis and the Kveim test done in three patients was negative. Our experience encourages us to recommend staging laparotomy for all adult patients with Hodgkin's disease which does not show obvious generalized spread beyond lymph nodes.