The effect of requesting a reason for non-adherence to a guideline in a long running automated reminder system for PONV prophylaxis.

BACKGROUND: Automated reminders are employed frequently to improve guideline adherence, but limitations of automated reminders are becoming more apparent. We studied the reasons for non-adherence in the setting of automated reminders to test the hypothesis that a separate request for a reason in itself may further improve guideline adherence. METHODS: In a previously implemented automated reminder system on prophylaxis for postoperative nausea and vomiting (PONV), we included additional automated reminders requesting a reason for non-adherence. We recorded these reasons in the pre-operative screening clinic, the OR and the PACU. We compared adherence to our PONV guideline in two study groups with a historical control group. RESULTS: Guideline adherence on prescribing and administering PONV prophylaxis (dexamethasone and granisetron) all improved compared to the historical control group (89 vs. 82% (p< 0.0001), 96 vs 95% (not significant) and 90 vs 82% (p<0.0001)) while decreasing unwarranted prescription for PONV prophylaxis (10 vs. 13 %). In the pre-operative screening clinic, the main reason for not prescribing PONV prophylaxis was disagreement with the risk estimate by the decision support system. In the OR/PACU, the main reasons for not administering PONV prophylaxis were: 'unintended non-adherence' and 'failure to document'. CONCLUSIONS: In this study requesting a reason for non-adherence is associated with improved guideline adherence. The effect seems to depend on the underlying reason for non-adherence. It also illustrates the importance of human factors principles in the design of decision support. Some reasons for non-adherence may not be influenced by automated reminders.

Lowering blood glucose during hip surgery does not influence coagulation activation.

BACKGROUND: Hyperglycaemia during and after hip surgery is associated with coagulation activation and an increased risk of venous thromboembolism. Whether lowering of glucose levels during hip surgery diminishes coagulation activation is unknown. We investigated the efficacy of the human GLP-1 analogue liraglutide to lower glucose during and after hip surgery and studied its influence on coagulation activation. METHODS: A total of 37 obese subjects who underwent hip surgery were randomized to subcutaneous liraglutide or placebo for 4 consecutive days, starting one day prior to surgery. Glucose levels and coagulation indices at three fixed time-points (pre-operative, 2 h post-operative and 3 days post-operative) were measured. RESULTS: Liraglutide reduced glucose at day three post-surgery (median glucose (IQR) liraglutide 5.5 (5.2-5.7) vs. placebo 5.8 (5.5-6.2); difference 0.3 mmol/L, P = 0.04). Changes in 6 out of 8 coagulation indices studied did not differ between the two groups. Only D-dimer levels were significantly lower in the liraglutide group at day three post-surgery and FVIII levels were significantly higher in the liraglutide group 2 h post-surgery. CONCLUSION: Although the human GLP-1 analogue liraglutide moderately reduced post-operative blood glucose levels in non-diabetic and prediabetic obese patients undergoing elective hip surgery, no changes were observed with respect to coagulation activation.

Automated reminders increase adherence to guidelines for administration of prophylaxis for postoperative nausea and vomiting.

BACKGROUND AND OBJECTIVE: Correct identification of patients at high risk for postoperative nausea and vomiting (PONV), prescription of PONV prophylaxis and correct administration of medication are all important for effective PONV prophylaxis. This has been acknowledged by development of guidelines throughout the world. We studied the effect of introducing patient-specific automated reminders on timely administration of PONV prophylaxis medication during general anaesthesia. METHODS: During the visit to the preoperative screening clinic, patients at high risk for PONV were identified and PONV prophylaxis was prescribed. To study the effect of patient-specific decision support [a pop-up window reminding the (nurse) anaesthetist that PONV prophylaxis had been prescribed for this particular patient] on the timely administration of PONV medication, we queried our database to extract data on all patients for three consecutive periods: 6 weeks before decision support (control), 12 weeks during decision support and 6 weeks after discontinuation of decision support (postdecision support) and studied how often PONV prophylaxis was administered correctly. RESULTS: Between November 2005 and May 2006, 1727, 2594 and 1331 patients presented for elective surgery in the control, decision support and postdecision support periods, respectively. In the control period, 236 patients receiving general anaesthesia were scheduled to receive PONV prophylaxis. Of these, 93 (39%) received both dexamethasone and granisetron in the correct timeframe. This increased to 464 (79%) out of 591 patients in the decision support period and decreased back to 99 (41%) out of 243 patients in the postdecision support period (P < 0.001). CONCLUSION: Decision support is effective in improving administration and timing of PONV prophylaxis medication. After withdrawal of decision support, adherence decreased to predecision support levels.

Decision support increases guideline adherence for prescribing postoperative nausea and vomiting prophylaxis.

BACKGROUND: Guidelines for postoperative nausea and vomiting (PONV) prevention are implemented widely but their effectiveness may be limited by poor adherence. We hypothesized that the use of an electronic decision support (DS) system would significantly improve guideline adherence. METHODS: Medical information of all patients undergoing elective surgery in our regional teaching hospital is routinely entered in an anesthesia information management system at the preoperative screening clinic. Our departmental PONV prevention guidelines identifies patients as "high-risk" and thus eligible for PONV prophylaxis based on the presence of at least three of the following risk factors: female gender, history of PONV or motion sickness, nonsmoker status, and anticipated use of postoperative opioids. Using automated reminders, we studied the effect of DS on guidelines adherence using an off-on-off design. In these three study periods, we queried for all consecutive patients visiting the preoperative screening clinic who were eligible for PONV prophylaxis and studied how often it was prescribed correctly. RESULTS: Between November 2005 and June 2006, 1340, 2715, and 1035 patients were included in the control, DS and post-DS periods, respectively. As a result of mandatory data entry of risk factors, the percentage of high-risk PONV patients increased from 28% in the control period to 32% and 31% in the DS and post-DS periods, respectively. During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis. This increased to 73% during the DS period and decreased to 37% in the post-DS period. CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.

Calcium channel blockade with felodipine does not affect metabolic coronary vasodilation in patients with coronary artery disease.

The effect of calcium channel blockers may affect the feedback mechanism between myocardial metabolic activity and coronary blood flow. To test this hypothesis the effect of calcium channel blockade on metabolic coronary flow regulation was studied. In 10 patients with stable coronary artery disease, coronary sinus blood flow and myocardial oxygen supply and consumption (MVO2) were measured both at sinus rhythm and during atrial pacing (30 beats/min above sinus rate), at control and during infusion of felodipine, a vasoselective dihydropyridine. The myocardial oxygen supply-consumption ratio at control (i.e., the slope of the regression line characterizing normal metabolic flow regulation) was 1.58 (95% CI, 1.38-1.80). Following infusion of felodipine, systemic and coronary vascular resistance during sinus rhythm decreased by 20 +/- 11% and 23 +/- 15%, respectively, and coronary venous oxygen saturation increased from 36 +/- 6% at control to 42 +/- 7% (p = 0.047) during infusion of felodipine. The myocardial oxygen supply-consumption ratio, characterizing metabolic flow regulation during felodipine, was 1.52 (95% CI, 1.26-1.78) and thus not different from control. Metabolic coronary flow regulation was not affected by administration of felodipine, although the setpoint of this regulation mechanism might have been offset by the initial drug-induced coronary vasodilation, which persisted during pacing.