The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women.

PURPOSE: Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline. SUBJECTS AND METHODS: We performed a population-based, before-and-after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occurrence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering within clinics. RESULTS: A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated. As compared with baseline, guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (RR = 0.73; CI, 0.68 to 0.79), and an initial office visit (RR = 0.67; CI, 0.62 to 0.73), while increasing the proportion who received a guideline-recommended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective comparison of the 22 intervention and two control clinics, the guideline decreased the proportion of patients who had urinalyses performed (RR = 0.80; CI, 0.65 to 0.98) and increased the proportion of patients who were prescribed a guideline-recommended antibiotic (RR = 1.53; CI, 1.01 to 2.33). Adverse outcomes did not increase significantly in either comparison. CONCLUSION: Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.

Successful implementation of an evidence-based clinical practice guideline: acute dysuria/urgency in adult women.

This paper describes the development and successful implementation of an evidence-based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses.

A survey of college health services: how widely are protocols used in the college health setting?

We developed a survey to assess the prevalence and use of protocols in college health services, using the college health nurse as the primary focus. Three thousand and twenty copies of the survey were mailed to individual and institutional members of the American College Health Association (ACHA), and 812 surveys were returned, yielding a return rate of 25%. The data, which came from all 50 states, Canada, and Guam, were then compiled and analyzed using computer software dBase III. The generalizability of the results are somewhat limited because some surveys were returned with unanswered questions and because duplicate surveys were received from some facilities.

Safe and effective IV regional anesthesia for use in the emergency department.

The mini-dose Bier block, a technique of intravenous (IV) regional anesthesia that uses low-dose lidocaine and provides safe and effective anesthesia for outpatient closed reductions of upper extremity fractures and dislocations, is presented. This procedure was evaluated in two hospital emergency departments in 105 patients (ages 2 to 86). Ninety-five percent achieved adequate anesthesia (minimal or no pain on closed reduction). No significant complications were noted. Full neurologic function returned in ten minutes in all cases. Both patient and physician satisfaction with the procedure were high. The mini-dose Bier block creates the potential for significant cost savings in cases previously treated in the operating room by providing a safe, effective technique of IV regional anesthesia for outpatient use.

Safe and effective IV regional anesthesia for use in the emergency department.

The mini-dose Bier block, a technique of intravenous (IV) regional anesthesia that uses low-dose lidocaine and provides safe and effective anesthesia for outpatient closed reductions of upper extremity fractures and dislocations, is presented. This procedure was evaluated in two hospital emergency departments in 105 patients (ages 2 to 86). Ninety-five percent achieved adequate anesthesia (minimal or no pain on closed reduction). No significant complications were noted. Full neurologic function returned in ten minutes in all cases. Both patient and physician satisfaction with the procedure were high. The mini-dose Bier block creates the potential for significant cost savings in cases previously treated in the operating room by providing a safe, effective technique of IV regional anesthesia for outpatient use.

Incomplete and inevitable abortion: treatment by suction curettage in the emergency department.

Suction curettage for inevitable and incomplete spontaneous abortion has been performed by emergency physicians in the emergency department of the Central Group Health Hospital in Seattle for more than seven years. The equipment and techniques used in our practice are described, and guidelines for treatment are presented. Also presented is an analysis of 111 consecutive patients treated with suction curettage during an 18-month period with a minimum follow up of six months. The complication rate was minimal (4.5%), and compares favorably with previously published results of inpatient treatment. Several significant advantages of treating incomplete and inevitable abortion with suction curettage in the emergency department are described.

Use of an observation ward in a community hospital.

A six-bed observation ward has been an integral part of our community hospital emergency department for 10 years. During a recent 4-month period, 574 patients were admitted with 65 different clinical presentations. Length of stay, treatment, complications, and disposition were evaluated. An estimated 1.7 hospital admissions per day were avoided at an annual cost savings of $240,000. Guidelines have been developed which avoid most potential pitfalls in the use of an observation ward. Significant flexibility is gained and improved patient care is possible with the addition of an observation ward to the emergency department.

Topical ethyl ether therapy of herpes simplex lesions.

A simple and effective method of treating herpes simplex lesions using topical application of ethyl ether relieves pain almost immediately and aborts progression of the lesion. The therapeutic rationale for using this modality is based on the ability of ether to penetrate the epidermis and to destroy the ether sensitive envelope of the virus. A decrease in frequency and even elimination of recurrences has been suggested.

Conservative management of fingertip amputations.

A method of conservative treatment of fingertip amputations, allowing for spontaneous healing of the defect, was evaluated in a one-year study involving 17 consecutive patients and 21 amputations. Six presented with exposed bone in the lesion. These injuries healed with excellent results in terms of maintenace of maximum finger length and minimization of cosmetic deformity and functional disability. Rapid retrun to work was possible in most cases and morbidity associated with surgery was avoided.