Do clinical guidelines enhance safe practice in obstetrics and gynaecology?

Clinical guidelines are increasingly used to promote a more uniform standard of high-quality evidence-based health care. International agencies advocate guideline development methods founded on three principles: that recommendations are evidence-based, are explicitly linked to the type and quality of evidence, and are developed by multidisciplinary stakeholder groups. Numerous interventions have been described to support the implementation of guidelines. Systematic reviews suggest that most interventions produce modest to moderate improvements in care; multifaceted interventions appear to be no more effective than single interventions, and the lowest-cost implementation strategy (dissemination of printed materials) may improve care and be feasible in many settings. Given the considerable costs of developing valid guidelines de novo, we advocate local adaptation of existing guidelines if available. We suggest a pragmatic framework to assist policy-makers and clinicians in deciding how best to use the scarce resources available for quality-improvement activities.

Impact on maternity professionals of novel approaches to clinical audit feedback.

The authors compared three approaches to feedback of clinical audit findings relating to miscarriage in 15 Scottish maternity services (printed report alone; report plus action planning letter; report plus face-to-face facilitated action planning). Clinicians were surveyed to measure theory of planned behavior constructs (in the context of two audit criteria) before and after feedback (n = 253) and assessed perceptions of the audit through in-depth interviews (n = 17). Prefeedback, clinicians had positive attitudes and strong subjective norms and intentions to comply, although perceived behavioral control was lower. Generally, positive attitudes, subjective norms, and intentions increased after feedback but for one of the two criteria (providing a 7-day miscarriage service), perceived behavioral control decreased. No changes over time reached statistical significance, and analysis of covariance (adjusting for prefeedback scores) showed no consistent relationships between method of feedback and postfeedback construct scores. Interviews revealed positive perceptions of audit but frustration at lack of capacity to implement changes. Although interventions that increased intensity of feedback proved feasible and acceptable to clinicians, the authors were unable to demonstrate that they increased intention to comply with audit criteria.

Treatment of pain during medical abortion.

A structured literature review was undertaken to determine, in the context of early medical abortion, the proportion of women who require analgesia, the predictors of analgesia requirement and the most appropriate analgesia regimen. Studies from different centers show wide variations in analgesia use, but, overall, around 75% of women use narcotic analgesics on the day of prostaglandin administration. Differences are likely to be due to differences in policies for offering analgesia rather than differences in patient characteristics. The following characteristics are consistently associated with increased requirement for analgesia: increasing gestation, younger patient age, nulliparity and White race. A regimen comprising 325-500 mg of paracetamol (acetaminophen) with 10 mg of dihydrocodeine or 30 mg of codeine has been used by thousands of women without apparent problems.

Terminology in early pregnancy loss: what women hear and what clinicians write.

OBJECTIVE: The Royal College of Obstetricians and Gynaecologists recommends that patient-focused terminology be used in early pregnancy care. The objective of the study was to evaluate whether inappropriate terminology is continuing to be used in Scottish gynaecology services. METHODS: A case note review (1259 records) and a patient survey (648 replies) assessed usage of four inappropriate terms ('abortion', 'blighted ovum', 'incompetent cervix' and 'pregnancy failure') in 18 Scottish hospitals providing secondary care to women with early pregnancy loss. RESULTS: Women reported hearing 'abortion' in 4.2% of hospital episodes (95% CI 2.9-6.0), but the term was used in 9.9% (95% CI 8.4-11.7) of hospital records. CONCLUSION: In order to meet national recommendations on terminology for early pregnancy loss, clinicians should not only say 'miscarriage' but also write it.

FFPRHC Guidance (July 2005): The use of contraception outside the terms of the product licence.

This Guidance provides information for clinicians and women considering the use of contraception outside the terms of the product licence. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: CEU, Clinical Effectiveness Unit; COC, combined oral contraception/contraceptive; DMPA, depot medroxyprogesterone acetate; ENG, etonogestrel; IUD, copper-bearing intrauterine contraceptive device; LNG-IUS, levonorgestrel-releasing intrauterine system; NET-EN, norethisterone enantate; PGD, Patient Group Direction; PIL, Patient Information Leaflet; POC, progestogen-only contraception/contraceptive; POEC, progestogen-only emergency contraception; POP, progestogen-only pill; RCT, randomised controlled trial; SPC, Summary of Product Characteristics; UPSI, unprotected sexual intercourse; WHO, World Health Organization; WHOMEC, WHO Medical Eligibility Criteria for Contraceptive Use; WHOSPR, WHO Selected Practice Recommendations for Contraceptive Use.

Attributes of clinical recommendations that influence change in practice following audit and feedback.

The object of this study was to determine which attributes of clinical practice recommendations influence changes in clinical practice following audit and feedback. This was an observational study using multilevel modeling to examine the relationship between attributes of clinical practice recommendations and compliance with the recommendations before and after audit and feedback. Sixteen hospital gynecology units in Scotland participated in a national audit project. Clinical practice recommendations covering selected gynecological topics were developed and data collected to assess baseline (preintervention) compliance. Summaries of performance were fed back to consultant gynecologists in each hospital and follow-up (postintervention) data were collected. Trained audit assistants used standardized forms to abstract data from case notes. Compliance data were available at baseline and follow-up for a total of 42 clinical practice recommendations. Altogether, 4,664 case notes contributed to baseline data and 4,382 to follow-up data. Thirteen attributes describing clinical practice recommendations were developed, based upon previous work, and pretested. A panel of seven consultant gynecologists rated the extent to which each of the 42 recommendations possessed each of the 13 attributes. The main outcome measures were the association of each attribute with compliance and with changes in clinical practice. Recommendations compatible with clinician values and not requiring changes to fixed routines were independently associated with greater compliance at baseline and follow-up. However, recommendations incompatible with clinician values were independently associated with greater change in practice following audit and feedback. Attributes of recommendations may influence the effectiveness of audit and feedback in secondary care. Recommendations seen as incompatible with clinician values are associated with lower compliance but greater behavioral change following audit and feedback.

A consensus process to adapt the World Health Organization selected practice recommendations for UK use.

The nominal group technique for consensus development was used to consider the World Health Organization Selected Practice Recommendations for Contraceptive Use for adoption or adaptation in the United Kingdom. The nominal group comprised 11 opinion leaders who agreed that 74% of the WHO recommendations were consistent with current UK practice. Of 63 recommendations considered by the group to be at odds with current practice, 23 were adopted with advice that United Kingdom practice should change in line with WHO. Twenty-five were adopted because, although the group felt that the WHO recommendation differed from practice in the UK, it was unable to reach a consensus on an alternative recommendation. Thirteen WHO recommendations underwent minor revision for UK use. The group rejected two further WHO recommendations [on the timing of starting low-dose progestogen-only contraception (POC) during lactation] but was unable to reach consensus on any alternative guidance. It was agreed clinicians should be left to decide for themselves how to advise breastfeeding women about when to start low-dose POC. A UK version of the WHO Selected Practice Recommendations should help to standardize practice and improve the quality of care for couples using contraception.

FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception.

This Guidance provides information for clinicians providing women with copper-bearing intrauterine devices as long-term contraception. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: acquired immune deficiency syndrome (AIDS); actinomyces-like organisms (ALOs); automated external defibrillator (AED); blood pressure (BP); British National Formulary (BNF); confidence interval (CI); copper-bearing intrauterine contraceptive device (IUD); emergency contraception (EC); Faculty Aid to Continuing Professional Development Topic (FACT); levonorgestrel-releasing intrauterine system (IUS); human immunodeficiency virus (HIV); Medicines and Healthcare products Regulatory Agency (MHRA); non-steroidal antiinflammatory drugs (NSAIDs); odds ratio (OR); pelvic inflammatory disease (PID); relative risk (RR); Royal College of Obstetricians and Gynaecologists (RCOG); Scottish Intercollegiate Guidelines Network (SIGN); sexually transmitted infection (STI); termination of pregnancy (TOP); World Health Organization (WHO); WHO Medical Eligibility Criteria (WHOMEC); WHO Selected Practice Recommendations (WHOSPR).

Near miss audit in obstetrics.

PURPOSE OF REVIEW: Over the past decade, there has been increasing interest internationally in studying maternal near misses, or severe morbidity, to complement traditional audit of maternal mortality. This review summarizes studies in this field published during 2005-2006. RECENT FINDINGS: There is wide variation among published studies in terms of definitions of near miss, sources of data, and assessment of quality of care. Some investigators focus on single categories of near miss (e.g. postpartum haemorrhage, obstetric hysterectomy, intensive care unit admission), whereas others include multiple categories (ranging from two to 14). Some groups identify cases from routinely collected administrative data; whereas others search hospital registers and individual case records. Many investigators make no attempt to assess quality of care or preventability, but restrict their studies to the reporting of rates of severe morbidity. Others assess care by means of interviews with survivors or case note review, but study only a sample of cases and cannot report incidence rates. A minority of investigators both report incidence rates and assess quality of care. SUMMARY: Near miss audit is increasingly used to complement maternal mortality review. Standardization of inclusion criteria and of methods for case assessment would facilitate comparisons over time and among countries.