Increasing Utilization of Scrubbing Devices for Peripheral Intravenous Disinfectable Needleless Closed Connectors.

Introduction Peripheral intravenous (IV) administration sets are a source of infection that increases morbidity, mortality, and healthcare costs. In this quality improvement project, we aimed to enhance compliance with peripheral IV hub disinfection at anesthesia induction to follow the American Society of Anesthesiologists (ASA) safe medication injection guidelines. Methods This study was conducted in the main operating suite of the University of Miami's principal hospital between June and October 2023. Audits of scrubbing device utilization by the anesthesiology team and focus groups were conducted before and after two educational interventions. Educational efforts focused on increasing compliance with peripheral IV disinfection using scrubbing devices.  Results Mean use per case, inferred from the number of devices dispensed, nearly doubled from 0.44 (95% CI, 0.37 to 0.59) to 0.82 (95% CI, 0.77 to 0.88) (P < 0.0001). Implications regarding steps to further enhance compliance are discussed. Conclusions Through a simple educational program, scrubbing device utilization increased significantly from baseline.

Adherence to Antimicrobial Prophylaxis Guidelines in Endourologic Procedures: Frequency and Related Outcomes.

Background: Surgical antimicrobial prophylaxis (SAP), when used appropriately based on evidence-based guidelines, can reduce the rate of infectious complications following endourologic procedures without compromising patient outcomes. Objectives: To investigate the appropriateness of the current SAP used in endourologic surgeries based on international guidelines and report their associated outcomes (urinary tract infection [UTI] and blood stream infection [BSI]). Design: Prospective cross-sectional study. Methodology: The medical records of patients undergoing endourologic procedures were reviewed to assess healthcare providers' adherence to international guideline recommendations. Assessed parameters included indication, duration, choice, and dose of the antibiotics used in endourologic procedures in two medical centers in Amman/Jordan. Furthermore, patients were asked to conduct laboratory urine tests to determine the rate of infectious complications within one month post-procedure. Results: Three hundred and sixty-one patients were recruited for the study. The adherence rates to guidelines regarding indication, choice, and dose of pre-operative antibiotics were 90.3%, 2.8%, and 77.8%, respectively. The duration was concordant with guidelines in only 3.4% of participants. A total of 41.8% of patients completed follow-up. Among those, 4.6% developed bacterial UTIs, and 0.7% developed BSI. Conclusion: Adherence to SAP guidelines in endourologic procedures was far from optimal. Primary deviations in the implementation of guidelines' recommendations were pinpointed. These results are crucial for planning interventions that optimize SAP utilization.

Implementation of a software-based decision support tool for guideline-appropriate preoperative evaluation: a prospective agreement study.

BACKGROUND: Guideline adherence in the medical field leaves room for improvement. Digitalised decision support helps improve compliance. However, the complex nature of the guidelines makes implementation in clinical practice difficult. METHODS: This single-centre prospective study included 204 adult ASA physical status 3-4 patients undergoing elective noncardiac surgery at a German university hospital. Agreement of clearance for surgery between a guideline expert and a digital guideline support tool was investigated. The decision made by the on-duty anaesthetists (standard approach) was assessed for agreement with the expert in a cross-over design. The main outcome was the level of agreement between digital guideline support and the expert. RESULTS: The digital guideline support approach cleared 18.1% of the patients for surgery, the standard approach cleared 74.0%, and the expert approach cleared 47.5%. Agreement of the expert decision with digital guideline support (66.7%) and the standard approach (67.6%) was fair (Cohen's kappa 0.37 [interquartile range 0.26-0.48] vs 0.31 [0.21-0.42], P=0.6). Taking the expert decision as a benchmark, correct clearance using digital guideline support was 50.5%, and correct clearance using the standard approach was 44.6%. Digital guideline support incorrectly asked for additional examinations in 31.4% of the patients, whereas the standard approach did not consider conditions that would have justified additional examinations before surgery in 29.4%. CONCLUSIONS: Strict guideline adherence for clearance for surgery through digitalised decision support inadequately considered patients, clinical context. Vague formulations, weak recommendations, and low-quality evidence complicate guideline translation into explicit rules. CLINICAL TRIAL REGISTRATION: NCT04058769.

The Influence of Active, Passive, and Manual Therapy Interventions on Escalation of Health Care Events After Physical Therapist Care in Veterans With Low Back Pain.

OBJECTIVE: The objective of this study was to examine the associations between active, passive, and manual therapy interventions with the escalation-of-care events following physical therapist care for veterans with low back pain (LBP). METHODS: A retrospective cohort study was conducted in 3618 veterans who received physical therapist care for LBP between January 1, 2015 and January 1, 2018. The VA Corporate Data Warehouse was utilized to identify LBP-related physical therapist visits and procedures, as well as opioid prescription and non-physical therapy clinic encounters. The association between physical therapist interventions with 1-year escalation-of-care events were assessed using adjusted odds ratios from logistic regression. RESULTS: Nearly all veterans (98%) received active interventions but only a minority (31%) received manual therapy. In the 1-year follow-up period, the odds of receiving an opioid prescription were 30% lower for those who received manual therapy in addition to active interventions, as compared with patients who received only active interventions. Moreover, the odds of receiving primary care, specialty care, and diagnostic testing were 30-130% higher for patients who received electrical stimulation or more than 1 passive intervention in addition to active treatments, as compared with patients who received only active interventions. CONCLUSION: The use of manual therapy along with active interventions was associated with reduced prescription of opioids, while utilization of specific passive interventions such as electrical stimulation or multiple modalities in conjunction with active interventions resulted in increased escalation-of-care events. IMPACT STATEMENT: The use of active interventions, which is supported by most Clinical Practice Guidelines (CPGs), was the cornerstone of physical therapist care for veterans with LBP. However, the use of CPG-recommended manual therapy interventions was low but associated with reduced opioid prescriptions. The use of 2 or more different passive interventions along with active interventions was common (34%) and associated with less-than-optimal escalation-of-care outcomes.

Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: A cluster-randomised trial by the European Society of Cardiology and European Heart Rhythm Association.

AIMS: To describe the rationale, design, delivery and baseline characteristics of STEEER-AF (Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European Society of Cardiology [ESC] in a cluster-Randomised trial in patients with Atrial Fibrillation). METHODS & RESULTS: STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice, and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomised in 6 countries (France, Germany, Italy, Poland, Spain and United Kingdom; 2022-2023). STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with mean age 68.9 years (SD 11.7), CHA2DS2-VASc score 3.2 (SD 1.8) and 647 (37%) women. 843 patients (49%) were in AF and 760 (44%) in sinus rhythm at enrolment. Oral anticoagulant therapy was prescribed in 1,543 patients (89%), with the majority receiving direct oral anticoagulants (1,378; 89%). Previous cardioversion, antiarrhythmic drug therapy or ablation was recorded in 836 patients (48.3%). 551 patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomised to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. CONCLUSION: The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice, and evaluate if a structured educational programme for healthcare professionals can improve patient-level care. REGISTRATION: Clinicaltrials.gov NCT04396418.

Physiotherapists' adherence to Clinical Practice Guidelines in fibromyalgia: a cross-sectional online survey.

To evaluate the level of knowledge and adherence to Clinical Practice Guidelines on fibromyalgia of physiotherapists in Spain. A cross-sectional study using an ad-hoc online survey was implemented to assess aspects on the assessment, treatment, and decision of the length of the therapeutic approach on fibromyalgia. Based on the results, professionals were classified as adherent, partially adherent, or non-adherent. The level of agreement with several statements on the condition was also evaluated across the professionals surveyed to evaluate the potential consensus. A total of 240 physiotherapists met inclusion criteria, amongst which 68 (28.33%) were adherent. The academic level of studies (Chi-square = 48.601, p-value = 0.001) and having had previous training in fibromyalgia (Chi-square = 151.011, p-value = 0.001) displayed statistically significant differences across adherence-based groups. Consensus was reached for 15 out of 24 statements. Our findings highlight the presence of an acceptable level of knowledge and adherence to clinical practice guidelines in the field of fibromyalgia among physiotherapists in Spain.Practice implicationsOur results also reveal the existence of an evidence-to-practice gap in the field, with potential room for improvement: further efforts on promoting and reinforcing the importance of evidence-based therapies are needed, from university teaching plans to clinical updates for daily practice.

Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for moderate to severe trauma.

OBJECTIVES: The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for moderate to severe trauma. METHODS: This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94 %, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 min, and transport to the trauma center or level 1 emergency department. Multivariable logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs). RESULTS: Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed-9,573 (24.8 %) in the young group, 15,296 (39.7 %) in the middle-aged group, 9,562 (24.8 %) in the old group, and 4,149 (10.8 %) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95 % CI = 0.84 (0.76-0.94)) and very old group (aOR 95 % CI = 0.68 (0.58-0.81)) than in the young group. CONCLUSION: We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of moderate to severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.

Pathology requesting in a regional Australian Emergency Department; an observational study comparing current practice with college guidelines.

INTRODUCTION: In 2018, the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA) produced a guideline to encourage appropriate pathology requesting in the Emergency Department (ED). OBJECTIVE: To assess adherence to the ACEM/RCPA pathology testing guideline in a regional ED. METHODS, DESIGN, SETTING AND PARTICIPANTS: This was a retrospective observational study conducted at a regional Australian ED over 7 days. Adults with a presenting complaint encompassed by the guideline were included. All blood tests were audited against the guideline recommendations and classified as indicated or non-indicated. Chi-squared analyses were performed to explore the association between presenting complaint and non-indicated testing. MAIN OUTCOME MEASURE: The primary outcome was the number of non-indicated blood tests. RESULTS: Forty percent of tests ordered were not clinically indicated, with non-indicated testing occurring during 87% of encounters. The C-reactive protein (CRP) was the test most frequently ordered outside of guidelines (94% non-indicated). Patients presenting with lower abdominal pain accounted for nearly one-quarter of all non-indicated tests. CONCLUSIONS: Blood tests were commonly requested outside of the guideline recommendations and interventions to improve pathology stewardship are required.

Effects of Practice Ownership and Integration of Health Services on Adherence to Diabetes Guidelines.

OBJECTIVE: There has been a trend toward hospital systems and insurers acquiring privately owned physician practices and subsequently converting them into vertically integrated practices. The purpose of this study is to observe whether this change in ownership of a medical practice influences adherence to clinical guidelines for the management of type 1 and type 2 diabetes. METHODS: This is an observational study using pooled cross-sectional data (2014-2016 and 2018-2019) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. A total of 7499 chronic routine follow ups and preventative care visits to non-integrated (solo and group physician practices) and integrated practices were analyzed to see whether guideline concordant care was provided. Measures included 7 services that are recommended annually for individuals with type 1 and type 2 diabetes (HbA1c, lipid panel, serum creatinine, depression screening, influenza immunization, foot examination, and BMI). RESULTS: Compared to non-integrated physician practices, vertically integrated practices had higher rates of hemoglobin A1C testing (odds ratio 1.58 [95% CI 1.07-2.33], P < .05), serum creatine testing (odds ratio 1.53 [95% CI 1.02-2.29], P < .05), foot examinations (odds ratio 2.03 [95% CI 0.98-4.22], P = .058), and BMI measuring (odds ratio 1.54 [95% CI 0.99-2.39], P = .054). There was no significant difference in lipid panel testing, depression screenings, or influenza immunizations. CONCLUSIONS: Our results show that integrated medical practices have a higher adherence to diabetes practice guidelines than non-integrated practices. However, rates of services provided regardless of ownership were low.

Risk assessment and the use of personal protective equipment in an emergency department: Differing perspectives of emergency and infection control clinicians. A video-vignette survey.

BACKGROUND: The use of personal protective equipment (PPE) in emergency departments (EDs) is an important defense during infectious disease emergencies. However, what counts as appropriate PPE in EDs is contentious and inconsistently implemented in practice. METHODS: An online scenario-based video survey was distributed through purposive sampling, and completed by 270 ED and infection prevention and control clinicians in Australia. A descriptive content analysis was performed on the data, and differences between groups were tested using Fisher exact test. RESULTS: Participants agreed that most items were required in both scenarios. Eye protection, mask use, and hand hygiene frequency were more contentious. Physicians were more likely than nurses, and ED clinicians more likely than infection prevention and control clinicians, to regard items or actions as optional rather than essential. Many ED clinicians, particularly physicians, regarded sequences as too time-consuming to be practical in a busy ED. DISCUSSION: Our findings likely reflect differences in professional roles, competing priorities, and risks, and highlight important contextual characteristics of EDs, such as diagnostic uncertainty, equipment inaccessibility, and resource constraints. CONCLUSIONS: To be feasible, practicable, and thereby effective, PPE guidance in the ED must be designed collaboratively with frontline ED staff, and reflects the complexities of their practice.

APPaRENT 3: Asthma Patients' and Physicians' Perspectives on the Burden and Management of Asthma in Seven Countries.

INTRODUCTION: Asthma management is strongly dependent on physician and patient beliefs and perceptions about the disease and its long-term treatment. The APPaRENT 3 study was conducted to explore factors influencing treatment choice and to understand patients' and physicians' attitudes and perspectives on the use of controller inhalers in regular versus flexible dosing for asthma management. METHODS: This cross-sectional survey of patients with asthma and treating physicians was conducted in seven countries: Indonesia, Malaysia, Philippines, Thailand, Vietnam (patient survey only), Saudi Arabia, and the United Arab Emirates. Assessment was carried out through an online/face-to-face questionnaire, where patients' viewpoints were focused on their attitudes and beliefs about asthma and treatment adherence, whereas physicians' viewpoints were gathered on their attitudes and beliefs about asthma management, knowledge of and adherence to asthma treatment guidelines, and asthma treatment regimens. RESULTS: Overall, 1400 patients (mean age, 34 years) and 599 physicians (mean age, 43 years) were included in the survey. Physicians similarly prioritised symptom control (39%) and exacerbation reduction (40%) in moderate asthma, whereas patients prioritised symptom control (41%) over exacerbation reduction (22%). Although both groups (physicians, 86%; patients, 84%) perceived asthma as well-controlled, poor management was evident based on Asthma Control Test (ACT) scores (mean, 15.7; standard deviation, 4.14; 82% had an ACT score < 20) and high symptom burden (39% reported nighttime awakenings or early mornings ≥ 2 nights/week). Most patients (76%) with moderate asthma were prescribed regular dosing, with the most common treatment being inhaled corticosteroid (ICS)/long-acting ß2-agonist (LABA) with as-needed inhaled short-acting ß2-agonist (SABA; 20%). Among patients on maintenance and reliever therapy, 93% of patients received a separate inhaled reliever. CONCLUSIONS: Despite high symptom burden, patients overestimated their level of asthma control. Physicians prioritised controlling symptoms and reducing exacerbations as treatment goals for moderate asthma, often prescribing regular dosing with ICS/LABA with as-needed inhaled SABA.

Managing asthma depends a lot on what doctors and patients think about the illness and its long-term treatment. This study looked into what influences treatment decisions and what patients and doctors think about using inhalers regularly or on an as-needed basis to manage asthma across seven countries (Indonesia, Malaysia, Philippines, Thailand, Vietnam [patient survey only], Saudi Arabia, and the United Arab Emirates). In this study, patients with asthma and doctors managing asthma completed an online/face-to-face questionnaire. The study aimed to understand what patients think about asthma and their treatment plan. Meanwhile, the doctors were asked what they think about managing asthma and how much they apply clinical guidelines for treating patients with asthma. Doctors believed it is equally important to control symptoms and prevent worsening of symptoms in patients with moderate asthma, while patients cared more about controlling symptoms than preventing worsening of symptoms. While doctors and patients both regarded asthma as well-controlled, many patients had low Asthma Control Test scores and experienced a lot of symptoms, suggesting that they are poor perceivers of asthma control. Most patients with moderate asthma were given regular treatment, usually with inhaled corticosteroid combined with long-acting ß₂-agonist along with as-needed short-acting ß₂-agonist as a reliever. Most patients who were prescribed the same inhaler for regular use and as a reliever also had a separate inhaler for quick relief of symptoms. This study shows the need for patients and doctors to have better conversations about asthma, its treatments, and what to expect from them.

Quality of care measurement for patients with ovarian cancer in Japan.

AIM: Quality of care is important to reduce disease progression, and improve both survival and quality of life. The Japan Society of Gynecologic Oncology has published treatment guidelines to promote standardized high-quality care for ovarian cancer in Japan. We developed quality indicators based on the guideline recommendations and used them on large datasets of health service use to examine the quality of ovarian cancer care. METHODS: A panel of experts developed the indicators using a modified Delphi method. Adherence to each indicator was evaluated using data from a hospital-based cancer registry of patients diagnosed in 2018. All patients receiving first-line treatment at participating facilities were included. The adherence rates were returned to participating hospitals, and reasons for nonadherence were collected. A total of 580 hospitals participated, and the study examined the care received by 6611 patients with ovarian cancer and 1879 with borderline tumors using 11 measurable quality indicators. RESULTS: The adherence rate ranged from 22.6% for "Estrogen replacement within 6 months of operation" to 93.5% for "Bleomycin, etoposide, and cisplatin for germ cell tumor more than Stage II." Of 580 hospitals, 184 submitted the reasons for nonadherence. CONCLUSIONS: The quality of ovarian cancer care should be continuously assessed to encourage the use of best practices. These indicators may be a useful tool for this purpose.

Urinary Tract Infection Guideline Adherence in a Dutch Sentinel Nursing Home Surveillance Network.

OBJECTIVES: To investigate guideline adherence 3 years after the introduction of a national guideline on urinary tract infections (UTIs) in frail older adults. Appropriate use of urine dipstick tests, treatment decisions, and antibiotic drug choices in residents with (suspected) UTIs without a catheter were examined. DESIGN: Observational prospective study. SETTING AND PARTICIPANTS: Nineteen nursing homes participating in a Dutch Sentinel Nursing Home Surveillance Network. METHODS: As of September 2021, for a 3-month period, medical practitioners recorded additional clinical information in the electronic health record in case of a (suspected) UTI. Based on this information, adherence to guideline recommendations was assessed. Nonadherence was classified into 2 categories: (1) "intentional nonadherence" as reported by practitioners and (2) "nonadherence otherwise" applied to all other cases where the recorded information was discordant with the guideline recommendations. RESULTS: A total of 532 cases of (suspected) UTIs from 469 residents were analyzed. In 455 cases (86%), dipsticks were used. For the 231 cases where clinical signs and symptoms already indicated no UTI treatment according to the guideline, a dipstick was still inappropriately ordered in 196 cases (85%). The decision to prescribe or withhold antibiotics was in 69% of the cases adherent, in 6% intentionally nonadherent, and in 25% nonadherent otherwise. The type of prescribed antibiotic was adherent to the recommended antibiotics for cystitis in 88% and for UTIs with signs of tissue invasion in 48%. Overall, for 40% of suspected UTIs, adherence to all relevant recommendations could be established, and in 9% practitioners reported intentional nonadherence to the guideline. CONCLUSIONS AND IMPLICATIONS: There is considerable room for improvement in all clinical stages of managing a suspected UTI in Dutch nursing homes, particularly with regard to the importance of patient's clinical signs and symptoms for appropriate dipstick use and antibiotic UTI treatments.

Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS: The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS: In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS: There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.

Aligning peripheral intravenous catheter quality with nursing culture-A mixed method study.

AIM: To explore barriers and facilitators that influence adherence to evidence-based guidelines for peripheral intravenous catheter care in different hospital wards. DESIGN: Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings. METHOD: Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire (PIVC-miniQ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings. RESULTS: The PIVC-miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: (1) Deviation from best practice, (2) Gaps in education and clinical training, (3) Quality variation between wards and (4) The importance of supportive leadership. CONCLUSION: This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards. IMPACT: The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated. REPORTING METHOD: The study adhered to the Good Reporting of A Mixed Method Study (GRAMM). PATIENT OR PUBLIC CONTRIBUTION: A patient representative has been involved in planning this study.

Regional differences in predictive biomarker testing rates for patients with metastatic NSCLC in the Netherlands.

BACKGROUND: Predictive biomarker testing has a key role in the treatment decision-making for patients with non-small cell lung cancer (NSCLC) and is mandated by (inter)national guidelines. The aim of this study was to establish guideline-adherent biomarker testing rates in the Netherlands in 2019 and to examine associations of demographical, clinical, and environmental factors with guideline-adherent testing. METHODS: This study involved the integration of clinical data of the Netherlands Cancer Registry with pathology reports of the Dutch Nationwide Pathology Databank. Data extracted from these reports included sample type, diagnosis, and molecular testing status of predictive biomarkers. The study population comprised all patients diagnosed with metastatic non-squamous NSCLC in the Netherlands in 2019. RESULTS: In the cohort of 3877 patients with metastatic non-squamous NSCLC under investigation, overall molecular testing rates for non-fusion predictive biomarkers (EGFR, KRAS, BRAF, ERBB2, MET) ranged from 73.9 to 89.0 %, while molecular testing for fusion-drivers (ALK, ROS1, RET, NTRK) ranged from 12.6 % to 63.9 %. Guideline-adherent testing of EGFR, KRAS, and ALK was performed in 85.2 % of patients, with regional rates spanning from 76.0 % to 90.8 %. Demographical and clinical factors associated with guideline-adherent biomarker testing included lower age (OR = 1.05 per one year decrease; p < 0.001), female sex (OR = 1.36; p = 0.002), diagnosis of adenocarcinoma (OR = 2.48; p < 0.001), availability of histological tumor material (OR = 2.46; p < 0.001), and clinical stage of metastatic disease (p = 0.002). Other factors associated with guideline-adherent biomarker testing included diagnosis at academic center (OR = 1.87; p = 0.002) and patient's region of residence (p < 0∙001). CONCLUSION: Optimization of the chain-of-care of predictive biomarker testing in patients with NSCLC in the Netherlands is needed to provide adequate care for these patients.

Clinicians' perceptions of "enhanced recovery after surgery" (ERAS) protocols to improve patient safety in surgery: a national survey from Australia.

BACKGROUND: Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians' perceptions of ERAS protocols in Australia. METHODS: A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS. RESULTS: The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were 'very knowledgeable' (n = 24; 13.6%) or 'knowledgeable' (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3-5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%). CONCLUSION: There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints.

Is the European Crohn's and Colitis organisation (ECCO) e-guide an acceptable and feasible tool for increasing gastroenterologists' guideline adherence? A mixed methods evaluation.

BACKGROUND AND AIMS: Management of inflammatory bowel disease is constantly evolving, increasing the importance for gastroenterologists to keep up to date with guidelines. Traditional implementation strategies have had only small positive impacts on clinical practice. eHealth strategies such as the European Crohn's and Colitis Organisation e-guide may be beneficial for clinician decision making in keeping with guidelines. The aim of this study was to evaluate the feasibility and acceptability of the e-guide. METHODS: A mixed methods approach was used to evaluate feasibility and acceptability. Cognitive (think-aloud) interviews were conducted with Australian gastroenterologists while using the e-guide. Two clinical scenarios were developed to allow evaluation of various aspects of the e-guide. Content analysis was applied to the qualitative interview data and descriptive analysis to the quantitative and observational data. RESULTS: Seventeen participants completed the study. Data saturation were reached. The ECCO e-guide was largely feasible and acceptable, as demonstrated by most clinical questions answered correctly, 87% reaching the answer within 3 min, and most feeling it was useful, would be beneficial to their practice and would use it again. Issues raised included difficulties with website navigation, layout of the e-guide and difficulties with access (network firewalls, paid subscription required). CONCLUSIONS: The ECCO e-guide is largely acceptable and feasible for gastroenterologists to use. Aspects of the e-guide could be modified to improve user experience. This study highlights the importance of engaging end-users in the development and evaluation of clinician educational tools.

Using electronic health records to evaluate the adherence to cervical cancer prevention guidelines: A cross-sectional study.

OBJECTIVE: The fight against cervical cancer requires effective screening together with optimal and on-time treatment along the care continuum. We examined the impact of cervical cancer testing and treatment guidelines on testing practices, and follow-up adherence to guidelines. METHODS: Data from Estonian electronic health records and healthcare provision claims for 50,702 women was used. The annual rates of PAP tests, HPV tests and colposcopies during two guideline periods (2nd version 2012-2014 vs 3rd version 2016-2019) were compared. To assess the adherence to guidelines, the subjects were classified as adherent, over- or undertested based on the timing of the appropriate follow-up test. RESULTS: The number of PAP tests decreased and HPV tests increased during the 3rd guideline period (p < 0.01). During the 3rd guideline period, among 21-29-year-old women, the adherence to guidelines ranged from 38.7% (44.4…50.1) for ASC-US to 73.4% (62.6…84.3) for HSIL and among 30-59-year-old from 49.0% (45.9…52.2) for ASC-US to 65.7% (58.8…72.7) for ASCH. The highest rate of undertested women was for ASC-US (21-29y: 25.7%; 30-59y: 21.9%). The rates of over-tested women remained below 12% for all cervical pathologies observed. There were 55.2% (95% CI 49.7…60.8) of 21-24-year-olds and 57.1% (95% CI 53.6…60.6) of 25-29-year-old women who received HPV test not adherent to guidelines. CONCLUSIONS: Our findings highlighted some shortcomings in guideline adherence, especially among women under 30. The insights gained from this study help to improve the quality of care and, thus, reduce cervical cancer incidence and mortality.