Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis.

BACKGROUND AND OBJECTIVES: A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS: This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS: The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS: Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.

The development of evidence-based care recommendations to improve the safe use of anticoagulants in children.

Evidence-based care recommendations and standardized protocols improve outcomes. In addition, anticoagulant management has been recognized by The Joint Commission (TJC) as an opportunity for improving patient safety. A National Patient Safety Goal requiring a standardized process for patients receiving anticoagulants was established by TJC. This requirement provided an opportunity to apply evidence-based care recommendations to the issue of safe anticoagulant use. To meet TJC requirement, the following searchable clinical question was drafted: "In children receiving anticoagulation therapy, what are the appropriate dosing, laboratory monitoring, timing, and dosing adjustments for warfarin, unfractionated heparin, and low-molecular-weight heparin to prevent coagulation-related complications?" The team used the Appraisal of Guidelines Research and Evaluation Collaboration (AGREE) instrument to evaluate the quality and relevance of identified guidelines in answering the clinical question. Best Evidence Statements (BESts) were developed for each of the medications (warfarin, low-molecular-weight heparin, and unfractionated heparin). BESts provide the format for the presentation of recommendations, discussion, and methods for point-of-care providers seeking synthesized evidence to guide care decisions. The primary goal of developing and implementing these statements was to standardize the use of anticoagulants and to prevent unsafe practices. A secondary goal was to ensure accessibility of the BESts throughout our organization, including the electronic medical record, various internal division home pages, and our organization's external website. The anticoagulant BESts developed at our organization show how an interprofessional approach to patient care results in the development of evidence-based care recommendations. The BESts were developed to standardize care associated with the use of anticoagulants and to provide dosing and monitoring parameters to ensure safe care to all patients receiving these medications. The development of evidence-based care recommendations can be accomplished with a focused interprofessional team dedicated to providing the safest possible care to patients.

Should breastfeeding mothers avoid allergenic foods?

Questions about maternal diet in lactation are common in clinical nursing practice, for nurses often work with breastfeeding women who are concerned about allergies, or who associate infant symptoms of crying or irritability to something they themselves have eaten. Can exposure to food proteins in a woman's diet actually cause food allergy in her breastfed child? Are special diets effective in managing infant allergic symptoms or gastrointestinal distress? The purpose of this article is to review the evidence related to diet for new breastfeeding mothers and make recommendations to guide clinical practice; seven such practice recommendations were developed after a thorough literature review. Nurses can use this literature summary to provide care based upon the best available research evidence.