Reducing errors in the administration of medication with infusion pumps in the intensive care department: A lean approach.

BACKGROUND: Medication errors occur frequently and may potentially harm patients. Administering medication with infusion pumps carries specific risks, which lead to incidents that affect patient safety. OBJECTIVE: Since previous attempts to reduce medication errors with infusion pumps failed in our intensive care unit, we chose the Lean approach to accomplish a 50% reduction of administration errors in 6 months. Besides improving quality of care and patient safety, we wanted to determine the effectiveness of Lean in healthcare. METHODS: We conducted a before-and-after observational study. After baseline measurement, a value stream map (a detailed process description, used in Lean) was made to identify important underlying causes of medication errors. These causes were discussed with intensive care unit staff during frequent stand-up sessions, resulting in small improvement cycles and bottom-up defined improvement measures. Pre-intervention and post-intervention measurements were performed to determine the impact of the improvement measures. Infusion pump syringes and related administration errors were measured during unannounced sequential audits. RESULTS: Including the baseline measurement, 1748 syringes were examined. The percentage of errors concerning the administration of medication by infusion pumps decreased from 17.7% (95% confidence interval, 13.7-22.4; 55 errors in 310 syringes) to 2.3% (95% confidence interval, 1-4.6; 7 errors in 307 syringes) in 18 months (p < 0.0001). CONCLUSION AND RELEVANCE: The Lean approach proved to be helpful in reducing errors in the administration of medication with infusion pumps in a high complex intensive care environment.

A flowchart for building evidence-based care bundles in intensive care: based on a systematic review.

PURPOSE: The Institute for Healthcare Improvement is the founder of the care bundled approach and described the methods used on how to develop care bundles. However, other useful methods are published as well. In this systematic review, we identified what different methods were used to design care bundles in intensive care units. The results were used to build a comprehensive flowchart to guide through the care bundle design process. DATA SOURCES: Electronic databases were searched for eligible studies in PubMed, EMBASE and CINAHL from January 2001 to August 2014. STUDY SELECTION: There were no restrictions on the types of study design eligible for inclusion. Methodological quality was assessed by using the Downs & Black-checklist or Appraisal of Guidelines, REsearch and Evaluation II. DATA EXTRACTION: Data extraction was independently performed by two reviewers. RESULTS OF DATA SYNTHESIS: A total of 4665 records were screened and 18 studies were finally included. The complete process of designing bundles was reported in 33% (6/18). In 50% (9/18), one of the process steps was described. A narrative report was written about care bundles in general in 17% (3/18). We built a comprehensive flowchart to visualize and structure the process of designing care bundles. CONCLUSION: We identified useful methods for designing evidence-based care bundles. We built a comprehensive flowchart to provide an overview of the methods used to design care bundles so that others could choose their own applicable method. It guides through all necessary steps in the process of designing care bundles.

Timely individual audit and feedback significantly improves transfusion bundle compliance-a comparative study.

OBJECTIVE: To investigate the difference in effect on transfusion bundle compliance between two Audit and Feedback (A&F) strategies to implement the transfusion bundle. DESIGN AND SETTING: This implementation study was conducted in an ICU of a university hospital from May to December 2014. The ICU consists of two nursing teams containing 63 and 62 nurses. PARTICIPANTS: All ICU nurses participated in this study. INTERVENTION: Monthly A&F on team level versus a combination of monthly A&F on team level plus timely individual feedback. MEASUREMENTS: The primary outcome was bundle compliance. Compliance was measured after every single transfusion. RESULTS: Monthly A&F on team level with timely individual A&F significantly improves bundle compliance during implementation compared to monthly A&F on team level alone. The overall effect of compliance during the study period was significantly higher with an OR of 4.05 (95% confidence interval, CI: 1.62 to 10.08), P < 0.001. This indicates that when using the combined A&F strategy nurses are more likely to be compliant to the bundle than when monthly A&F was used alone. CONCLUSIONS: Compared to monthly team A&F alone, providing timely individual A&F plus monthly A&F on team level significantly improves the success of implementing a transfusion bundle on the ICU during the implementation period. Providing timely individual A&F plus monthly A&F on team level might also be effective for the implementation of other bundles in healthcare. Future research could elaborate on longer duration of the intervention, the use of information and computer technology to lower costs of the intervention, and to enhance sustainability.

Emergency care within hospitals: can it be done more efficiently?

INTRODUCTION: Cardiac Arrest Teams (CATs) are frequently activated by nurses when patients experience 'false arrests' (FAs). In those cases activation of the Rapid Response Team (RRT) might be more efficient. The authors determined the level of urgency of FAs to find a scope for improvement in efficiency within emergency care. METHODS: CAT-activations for FAs in a university hospital from September 2009 to 2012 were retrospectively analysed and classified as urgent or less-urgent. RESULTS: In 26% (107/405) the CAT was activated for FAs. Calls were classified as urgent in 43% (46/107). Less urgent calls comprised 57% (61/107) of the FAs, difference 14% (95%CI: 1% to 26%). CONCLUSIONS: A significant part of the CAT-activations for FAs were less urgent and an RRT-activation might be more efficient. To minimise the CAT-activations for FAs, nurses need to recognise early patients who clinically deteriorate. Therefore, nurses should use the Modified Early Warning Score correctly.

What are effective strategies for the implementation of care bundles on ICUs: a systematic review.

BACKGROUND: Care bundles have proven to be effective in improving clinical outcomes. It is not known which strategies are the most effective to implement care bundles. A systematic review was conducted to determine the strategies used to implement care bundles in adult intensive care units and to assess the effects of these strategies when implementing bundles. METHODS: The databases MEDLINE/PubMed, Ovid/Embase, CINAHL and CENTRAL were searched for eligible studies until January 31, 2015. Studies with (non)randomised designs on central line, ventilator or sepsis bundles were included if implementation strategies and bundle compliance were reported. Methodological quality was assessed by using the Downs and Black checklist. Data extraction and quality assessments were independently performed by two reviewers. RESULTS: In total, 1533 records were screened and 47 studies were finally included. In 49 %, pre/post designs were used, 38 % prospective cohorts, and the remaining studies used retrospective designs (6 %), interrupted time series (4 %) and longitudinal designs (2 %). The methodological quality was classified as 'fair' in 77 %, and the remaining as 'good' (13 %) and 'poor' (11 %). The most frequently used strategies were education (86 %), reminders (71 %) and audit and feedback (63 %). Our results show that compliance is influenced by multiple factors, i.e. types and numbers of elements varied and different compliance measurements were reported. Furthermore, compliance was calculated within different time frames. Also, detailed information about compliance, such as numerators and denominators, was not reported. Therefore, recalculation of consistent monthly compliance levels was not possible. CONCLUSIONS: The three most frequently used strategies were education, reminders and audit and feedback. We conclude that the heterogeneity among the included studies was high due to the variety in study designs, number and types of elements and types of compliance measurements. Due to the heterogeneity of the data and the poor quality of the studies, conclusions about which strategy results in the highest levels of bundle compliance could not be determined. We strongly recommend that studies in quality improvement should be reported in a formalised way in order to be able to compare research findings. It is imperative that authors follow the standards for quality improvement reporting excellence (SQUIRE) guidelines whenever they report quality improvement studies.

Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: a quasi-experimental study.

PURPOSE: To study the effect of protocolized measurement (three times daily) of the Modified Early Warning Score (MEWS) versus measurement on indication on the degree of implementation of the Rapid Response System (RRS). METHODS: A quasi-experimental study was conducted in a University Hospital in Amsterdam between September and November 2011. Patients who were admitted for at least one overnight stay were included. Wards were randomized to measure the MEWS three times daily ("protocolized") versus measuring the MEWS "when clinically indicated" in the control group. At the end of each month, for an entire seven-day week, all vital signs recorded for patients were registered. The outcomes were categorized into process measures including the degree of implementation and compliance to set monitoring standards and secondly, outcomes such as the degree of delay in physician notification and Rapid Response Team (RRT) activation in patients with raised MEWS (MEWS≥3). RESULTS: MEWS calculations from vital signs occurred in 70% (2513/3585) on the protocolized wards versus 2% (65/3013) in the control group. Compliance with the protocolized regime was presents in 68% (819/1205), compliance in the control group was present in 4% (47/1232) of the measurements. There were 90 calls to primary physicians on the protocolized and 9 calls on the control wards. Additionally on protocolized wards, there were twice as much RRT calls per admission. CONCLUSIONS: Vital signs and MEWS determination three times daily, results in better detection of physiological abnormalities and more reliable activations of the RRT.

Reduction of unnecessary use of indwelling urinary catheters.

BACKGROUND: The most effective way to reduce catheter-associated urinary tract infections (CA-UTIs) is to avoid unnecessary urinary catheterisation and to minimise the duration of catheterisation. AIM: To implement and assess the effect of an intervention to reduce the duration of urinary tract catheterisation. METHODS: This quality improvement project was set up as a before-after comparison consisting of a 2-month pre-intervention period, a period in which the intervention was implemented and a 2-month post-intervention period. The intervention included educational sessions to increase physicians' awareness and the daily reassessment of catheter use. The primary endpoint was the duration of catheterisation. Secondary endpoints were the catheter utilisation ratio, the length of hospital stay, the number of hospital-acquired symptomatic CA-UTIs and the number of appropriate indications for catheterisation. RESULTS: During the total study period, 149 patients (18.3%) were catheterised at some time during their hospital stay. There was a statistically significant decrease in the duration of catheterisation (median 7 vs 5 days; p<0.01), length of hospital stay (median 13 vs 9 days; p<0.01), and number of hospital-acquired CA-UTIs (4 vs 0, p=0.04) in the pre-intervention versus post-intervention period. CONCLUSIONS: An intervention to raise more awareness of the risks of inappropriate catheterisation can reduce the duration of catheterisation along with the length of hospital stay and the number of hospital-acquired symptomatic CA- UTIs, even in a short period of time.

Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis.

OBJECTIVE: To summarize the evidence available on the effects of decision aids in surgery. BACKGROUND: When consenting to treatment, few patients adequately understand their treatment options. To help patients make deliberate treatment choices, decision aids provide evidence-based information on the disease, treatment options, and their associated benefits and harms. Although decision aids are not designed to direct patients toward a particular treatment option, it is possible that their introduction will change the proportion of patients that opt for surgery. METHODS: We searched electronic databases for studies that evaluated a decision aid in patients offered both surgery and alternative treatment options, regarding the effect on the actual treatment choices made. In addition, we documented effects on knowledge, decisional conflict, anxiety, quality of life, patient involvement, satisfaction, mortality, morbidity, and costs. RESULTS: Seventeen studies were included. Overall, methodological study quality was good. Patients in the decision aid group less often chose to undergo invasive treatment [risk ratio = 0.80; 95% confidence interval, 0.67-0.95), had more knowledge about treatment options [mean difference = 8.99; 95% confidence interval, 3.20-14.78), and experienced less decisional conflict (mean difference = -5.04; 95% confidence interval, -7.10 to -2.99). Levels of anxiety and quality of life were similar. CONCLUSIONS: Offering a decision aid increases the number of patients who prefer conservative or less invasive treatment options. As decision aids improve patient knowledge and lower decisional conflict without raising anxiety levels, they have a place in surgery to help surgeons and patients achieve well-considered and shared treatment decisions.

Interpreting patient decisional conflict scores: behavior and emotions in decisions about treatment.

BACKGROUND: Patient decision aids facilitate treatment decisions. They are often evaluated in terms of their effect on decisional conflict, as measured by the Decisional Conflict Scale (DCS). It is unclear to what extent lower DCS scores are accompanied by observable patient behavior or emotions. OBJECTIVE: To help interpret DCS scores. DESIGN: In a Dutch university hospital, statements on behaviors or emotions during decision making were collected from asymptomatic aneurysm patients and healthy employees. Subsequently, they rated the intensity of decisional conflict that each statement expresses on a 1 to 10 scale. Selected statements were prospectively tested in aneurysm patients and cancer patients facing treatment dilemmas. MEASUREMENTS: Associations between patients' DCS scores and reported behavior and emotions were analyzed using logistic regression analysis. RESULTS: Participants provided 363 statements on behaviors and emotions during decision making, of which 28 were mentioned more than 4 times. Nine forms of behavior and emotions were selected as they were graded with the least variable median ratings of intensity of decisional conflict. Among 100 patients facing a treatment dilemma, each point increase in DCS lowered their odds for "immediately making the decision" (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.98), whereas the odds of "fretting regularly" (OR, 1.05; 95% CI, 1.02-1.08) and "feeling nervous when thinking of the decision" (OR, 1.04; 95% CI, 1.01-1.06) where higher. CONCLUSIONS: A decrease in decisional conflict scores leads to less decision postponing behavior, fretting, and nervousness. Research should focus on which DCS scores are needed to make deliberate decisions and which scores hinder patients in decision making.

Long-term adherence to a local guideline on postoperative body temperature measurement: mixed methods analysis.

AIM: To find out whether a successful multifaceted implementation approach of a local evidence-based guideline on postoperative body temperature measurements (BTM) was persistent over time, and which factors influenced long-term adherence. METHODS: Mixed methods analysis. Patient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus group meetings for nurses and a plenary meeting with an interactive questionnaire for doctors. RESULTS: Records from 102 surgical patients were studied, totalling 1226 BTM. According to the guideline, an indication for BTM was present in 55% (679/1226). Actually, BTM were taken in 60% (736/1226), of which 55% (403/736) was in accordance with the guideline. The overall adherence rate to the guideline was 50% (617/1226). Belief in the advantages of the guideline and strong staff support appeared to facilitate long-term adherence. Barriers were, the controversial nature of the guideline, the lack of self-efficacy among nurses and doctors as to clinical judgement to identify an infection when refraining from BTM, and a lack of management and staff doctor support. Furthermore, newly appointed nurses and doctors were trained to measure BTM during their initial medical or nursing education, which was in contradiction with the guideline. CONCLUSIONS: A multifaceted implementation strategy is not sufficient to maintain long-term adherence. To ensure long-term adherence, especially of controversial guidelines, adherence should be monitored and reported regularly over time. Strong staff support and leadership on all wards is crucial to maintain awareness. Medical and nursing curricula should include the pros and cons of taking BTM, combined with enhancing self-efficacy.

Utilizing new evidence in the prevention of recurrent preterm birth.

OBJECTIVE: Treatments that have proven to be effective in large randomized controlled trials are implemented in clinical practice at varying rates. We measured to what extent new and established strategies were applied to prevent recurrent preterm birth in the Netherlands. METHODS: In two academic hospitals, two non-academic teaching hospitals and two non-academic, non-teaching hospitals, we reviewed charts of all women who had delivered in 2006 and at that time had a history of spontaneous preterm birth before 34 weeks. We compared the application of preventive treatments between different types of hospitals. RESULTS: Ninety-one records were identified. In academic centers, screening for bacterial vaginosis and progesterone treatment were applied more often than in other centers (49 vs. 14%, p-value 0.001 and 63 vs. 22%, p-value <0.001, respectively). Cervical length measurement was applied more often in non-academic hospitals (58 vs. 39%, p-value 0.07), but with fewer measurements per patient (average of 3.3 vs. 5.8). CONCLUSION: In the management of women with a history of preterm birth, there is large practice variation. Relatively new treatments such as progesterone injections and screening for bacterial vaginosis are applied more frequently in academic centers, whereas cervical length measurement is more often performed in non-academic hospitals.

Measuring adherence among nurses one year after training in applying the Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments.

BACKGROUND: Patients with a cardiac arrest or unplanned intensive care admission show gradual decline in clinical condition preceding the event. This can be objectified by measuring the vital parameters and subsequently determining the Modified Early Warning Score (MEWS). Contact with the physician by nurses may be structured using the Situation-Background-Assessment-Recommendation (SBAR) communication instrument. The aim of our study was to evaluate whether nurses trained in the use of MEWS and SBAR tools were more likely to recognize a deteriorating patient. DESIGN AND SETTING: This prospective quasi-experimental trial in the Academic Medical Center in Amsterdam, the Netherlands included three medical and three surgical wards. INTERVENTIONS: A group of 47 trained and 48 non-trained nurses were presented with a case of a deteriorating patient, and subsequent assessment and actions regarding the patient case were measured. RESULTS: Of the trained nurses, 77% versus 58% of the non-trained group assessed the patient immediately. On subsequent assessment of the patient, respiratory rate was measured twice as frequently (53% trained versus 25% non-trained, p=0.025). No differences were found in the measurement of other vital parameters. The MEWS was determined by 11% of trained nurses. Subsequent notification of the physician was performed by 67% of the trained versus 43% of the non-trained nurses. The SBAR communication tool was used by only one nurse. CONCLUSIONS: Trained nurses are able to identify a deteriorating patient and react more appropriately. However, despite rigorously implementing MEWS/SBAR methodology, these tools were rarely used.

Factors determining the adoption of innovative needle suspension techniques with mesh to treat urogenital prolapse: a conjoint analysis study.

OBJECTIVES: This study was undertaken to determine which characteristics of proposed innovative surgical procedures influence the choice of pelvic floor surgeons when considering the use of mesh prostheses in the surgical treatment of urogenital prolapse. STUDY DESIGN: The survey was conceived using conjoint analyses technique. Opinion leaders were consulted in order to define six characteristics that were considered most relevant when evaluating a new mesh technique to treat urogenital prolapse. These characteristics were: scientific evidence, post-operative pain, erosion risk, required surgical skill, duration of hospital stay and costs. In 2007 the questionnaire was sent to the members of the Flemish and Dutch Societies for Obstetrics and Gynecology. Participants were presented with scenarios in which several possible combinations of levels of characteristics of the treatment are compared. A seven-point Likert scale was used to rate the willingness to adopt the new technique. Mixed model analysis of variance was used to determine the relative effects of the six characteristics of the new mesh technique. RESULTS: The level of scientific evidence emerged as the most important factor on willingness to adopt the new technique, with an estimated effect (beta coefficient) of +1.59, followed by the risk to develop erosion, with an estimated effect of +1.53. The decision whether to perform a novel needle suspension technique with mesh was further, but less, influenced by pain (beta=+0.82), costs (beta=+0.41), and required surgical skill (beta=+0.26) and least by the duration of the patient's hospital admission (beta=+0.18). CONCLUSIONS: The results of our study underscore the idea that physicians consider it highly relevant that there exists scientific evidence that supports the use of innovative surgical techniques. In urogynecology, the surgeons seem to consider research in the properties of the mesh to be very significant. This observation implies a responsibility for both the manufacturers of these devices, who will have to invest in gathering evidence and delay widespread introduction of them before clinical data are available, as well as for the physicians, who should either participate in clinical trials or await the results of these studies before adopting a new technique.

Use of progesterone treatment for the prevention of recurrent preterm birth: identification of obstacles to change.

Progesterone treatment has proven to be effective in preventing recurrent preterm birth. The use of progesterone varies widely between different obstetric clinics in the Netherlands. The study aimed to identify factors that hamper or facilitate the use of progesterone to create an implementation strategy. A Web-based survey was developed containing questions on sociopolitical factors, organizational factors, knowledge, and attitude. This survey was spread among 212 gynecologists, 203 midwives, and 130 women with a recent preterm birth. Response rates were 46% for gynecologists, 57% for midwives, and 78% for patients. Twenty-five percent of gynecologists were prescribing progesterone, 21% of midwives would recommend progesterone, and 54% of patients were willing to undergo treatment in future pregnancies. Specific factors hampering implementation for gynecologists were working in nonteaching hospitals and absence of progesterone treatment in local protocols. For midwives and patients, unfamiliarity with progesterone was the most notable finding. The major reason for failure of implementation of progesterone treatment to prevent recurrent preterm birth is absence of this treatment in protocols and lack of familiarity with this treatment in midwives and patients. This may be overcome through adjustment of clinical protocols on regional and national levels.

[Choosing between different treatment options: how should I inform my patients?]. / Kiezen tussen verschillende behandelopties; hoe informeer ik mijn patiënt?

Evidence-based medicine promotes the use of best available evidence to improve the transparency and quality of health care. The physician's clinical expertise and patient preferences are also important. Clear communication with the patient, based on available evidence from scientific research, is pivotal to making a balanced treatment choice, particularly when several equivalent treatment options are available. Although cure is obviously the aim of any medical intervention a certain risk of damage is always involved. Several verbal, numerical and graphical methods are available to inform the patient, with the aim of enabling the patient to make an informed choice when taking part in decisions on available treatment options. The aim should be to explain both beneficial and harmful effects of medical interventions in a straightforward manner. However, the amount and content of this information should be tailored to the patient's wishes.

Occlusive vs gauze dressings for local wound care in surgical patients: a randomized clinical trial.

OBJECTIVE: To compare effectiveness and costs of gauze-based vs occlusive, moist-environment dressing principles. DESIGN: Randomized clinical trial. SETTING: Academic Medical Center, Amsterdam, the Netherlands. PATIENTS: Two hundred eighty-five hospitalized surgical patients with open wounds. INTERVENTION: Patients received occlusive (ie, foams, alginates, hydrogels, hydrocolloids, hydrofibers, or films) or gauze-based dressings until their wounds were completely healed. MAIN OUTCOME MEASURES: Primary end points were complete wound healing, pain during dressing changes, and costs. Secondary end point was length of hospital stay. RESULTS: Time to complete wound healing did not differ significantly between occlusive (median, 66 days; interquartile range [IQR], 29-133 days) and gauze-based dressing groups (median, 45 days; IQR, 26-106 days; log-rank P = .31). Postoperative wounds (62% of the wounds included) healed significantly (P = .02) quicker using gauze dressings (median, 45 days; IQR, 22-93 days vs median, 72 days; IQR, 36-132 days). Median pain scores were low and similar in the occlusive (0.90; IQR, 0.29-2.34) and the gauze (0.64; IQR, 0.22-1.95) groups (P = .32). Daily costs of occlusive materials were significantly higher (occlusive, euro6.34 [US $9.95] vs gauze, euro1.85 [US $2.90]; P < .001), but nursing time costs per day were significantly higher when gauze was used (occlusive, euro1.28 [US $2.01] vs gauze, euro2.41 [US $3.78]; P < .001). Total cost for local wound care per patient per day during hospitalization was euro7.48 (US $11.74) in the occlusive group and euro3.98 (US $6.25) in the gauze-based group (P = .002). CONCLUSIONS: The occlusive, moist-environment dressing principle in the clinical surgical setting does not lead to quicker wound healing or less pain than gauze dressings. The lower costs of less frequent dressing changes do not balance the higher costs of occlusive materials. Trial Registration trialregister.nl Identifier: 56264738.

Antibiotic prophylaxis in urologic procedures: a systematic review.

OBJECTIVE: Antibiotic prophylaxis is used to minimize infectious complications resulting from interventions. Side-effects and development of microbial resistance patterns are risks of the use of antibiotics. Therefore, the use should be well considered and based on high levels of evidence. In this review, all available evidence on the use of antibiotic prophylaxis in urology is gathered, assessed, and presented in order to make choices in the use of antibiotic prophylaxis on the best evidence currently available. METHODS: A systematic literature review was conducted, searching Medline, Embase (1980-2006), the Cochrane Library, and reference lists for relevant studies. All selected articles were reviewed independently by two, and, in case of discordance, three, reviewers. RESULTS: Only the transurethral resection of prostate (TURP) and prostate biopsy are well studied and have a high and moderate to high level of evidence in favour of using antibiotic prophylaxis. Other urologic interventions are not well studied. The moderate to low evidence suggests no need for antibiotic prophylaxis in cystoscopy, urodynamic investigation, transurethral resection of bladder tumor, and extracorporeal shock-wave lithotripsy, whereas for therapeutic ureterorenoscopy and percutaneous nephrolithotomy, the low evidence favours the use of antibiotic prophylaxis. Urologic open and laparoscopic interventions were classified according to surgical wound classification, since no studies were identified. Antibiotic prophylaxis is not advised in clean surgery, but is advised in clean-contaminated and prosthetic surgery. CONCLUSIONS: Except for the TURP and prostate biopsy, there is a lack of well-performed studies investigating the need for antibiotic prophylaxis in urologic interventions.

Physicians and nurses focus on different aspects of guidelines when deciding whether to adopt them: an application of conjoint analysis.

OBJECTIVES: The objectives of this study are to determine the relative importance of 6 guideline features for physicians' and nurses' willingness to adopt practice guidelines, to examine whether physicians and nurses focus on the same or on different aspects of guidelines, and to test whether professionals' learning preference influences their willingness to adopt guidelines. METHODS: An orthogonal main effects design was used to develop 16 written guideline descriptions, which varied on 6 characteristics: 1) benefit for the professional, 2) source, 3) support by management, 4) scientific basis, 5) costs, and 6) subject. These descriptions were presented to 251 physicians and 110 nurses working at the Academic Medical Center in Amsterdam, The Netherlands. They indicated their willingness to adopt each guideline on a 7-point scale and completed Kolb's Learning Style Inventory to determine their preferred learning style. RESULTS: The response rate was 55% for physicians and 66% for nurses. The mean age was 40 years; 55% and 25% of the respondents were male. The mean adoption score was 5.26 for physicians and 5.00 for nurses. Of the 6 characteristics, "scientific basis" was found to be the strongest determinant for physicians, and the factor "interesting subject'' was the strongest for nurses. The other characteristics had a limited effect. Theoretically oriented physicians had a significantly lower average score compared with those who preferred active experimentation. No such effects were observed with nurses. CONCLUSIONS: Adherence to guidelines is influenced by internal as well as contextual attributes of guidelines. Physicians and nurses focus on different aspects, which is partly influenced by their preferred learning style. This difference in focus should be taken into account when developing an implementation strategy.

Design and development of a decision aid to enhance shared decision making by patients with an asymptomatic abdominal aortic aneurysm.

OBJECTIVE: To design, develop, and evaluate an evidence-based decision aid (DA) for patients with an asymptomatic abdominal aortic aneurysm (AAA) to inform them about the pros and cons of their treatment options (ie, surgery or watchful observation) and to help them make a shared decision. METHODS: A multidisciplinary team defined criteria for the desired DA as to design, medical content and functionality, particularly for elderly users. Development was according to the international standard (IPDAS). Fifteen patients with an AAA, who were either treated or not yet treated, evaluated the tool. RESULTS: A DA was developed to offer information about the disease, the risks and benefits of surgical treatment and watchful observation, and the individual possibilities and threats based on the patient's aneurysm diameter and risk profile. The DA was improved and judged favorably by physicians and patients. CONCLUSION: This evidence-based DA for AAA patients, developed according to IPDAS criteria, is likely to be a simple, user-friendly tool to offer patients evidence-based information about the pros and cons of treatment options for AAA, to improve patients' understanding of the disease and treatment options, and may support decision making based on individual values.