Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers.

BACKGROUND: Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines' acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability. OBJECTIVE: To examine the clinical acceptability of guidelines having excellent technical quality. DESIGN AND MEASUREMENTS: We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including "perceived comprehensiveness" (perceived relevance to common clinical situations) and "perceived validity" (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders. RESULTS: Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as "comprehensive" and 6% to 50% as "valid". CONCLUSION: Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

BACKGROUND: Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable. OBJECTIVES: To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software ("smart pump") and to suggest potential improvements in smart-pump design. DESIGN: Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges. PARTICIPANTS: 4,604 critically ill adults at 1 academic and 1 nonacademic hospital. MEASUREMENTS: Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs. RESULTS: Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps' capabilities might enable them to prevent more IV-ADEs. CONCLUSION: The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

360-Degree Feedback Model to Enhance Interprofessional Learning.

This article was migrated. The article was marked as recommended. Background: Providing meaningful feedback in interprofessional education (IPE) requires knowledge of discipline specific responsibilities and a method for measuring team dynamics while capturing individual performance. Methods: We implemented a 360-degree performance feedback model for a large-scale IPE simulation with standardized patients (SP) who transitioned from primary care to the emergency department. 293 medical, nursing, and pharmacy students were divided into 72 teams. We conducted a retrospective study evaluating feedback from 108 facilitators on individual and team based competencies, 12 SP patient satisfaction surveys and 293 student self-appraisals. We analyzed data using descriptive statistics and ANOVA for multiple group comparisons. Results: More than 94% of SP indicated they would return to the same student team to seek care. However, SP reported that the students did not summarize or clarify information, adapt to their level of understanding or encourage questions. Facilitators noted all disciplines were involved in formulating and implementing treatment plans. Student teams performed highest in mutual support and situational monitoring, and lowest in leadership and team structure. Students across all disciplines rated their teams as requiring light to no supervision. Conclusion: Applying the 360-degree performance model is feasible in IPE and provides multidimensional, qualitative feedback to enhance student learning.

Notch and Schwann cell transformation.

Benign plexiform neurofibromas in NF1 patients can transform spontaneously into malignant peripheral nerve sheath tumors (MPNSTs). Although mutations in the p53 gene have been found in a subset of MPNSTs and mouse models support a role for p53 mutations in malignant conversion, we found that each of three Schwann cell lines derived from human MPNSTs possessed active p53. One of the lines expressed the Notch intracellular domain (NICD), indicative of ongoing Notch signaling. Consistent with a role in malignancy, NICD was able to transform primary rat Schwann cells. Transformation was robust--NICD-transduced cells generated tumors in nude rats--and was associated with the loss of markers associated with Schwann cell differentiation. These data suggest that aberrant Notch signaling may contribute to the conversion of benign neurofibromas to MPNSTs.

Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California.

OBJECTIVE: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. METHOD: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. RESULTS: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. CONCLUSION: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority.

Does the collaborative model improve care for chronic heart failure?

BACKGROUND: Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF). RESEARCH DESIGN: We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations. RESULTS: Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001). CONCLUSIONS: Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases.

An analysis of standardised patient checklist errors and their effect on student scores.

BACKGROUND: The frequency and nature of standardised patient (SP) recording errors during clinical performance examinations (CPX) have an effect on case scores and ultimately on pass/fail decisions. PURPOSE: To determine the effect of SP recording errors on case scores. METHODS: Standardised patients completed checklists immediately after each encounter. To determine checklist accuracy, multiple reviewers developed a checklist key for each student encounter studied. The total errors, the net errors, the errors of commission and omission and error rates by competency skill were analysed. RESULTS: The frequency of errors in history taking was greater than in physical examination, and the majority of errors were made in the students' favour. Summing the errors of commission and omission decreased the effect of total errors on student scores. CONCLUSIONS: High levels of SP recording accuracy are achievable. When errors occur, the net effect is usually in the students' favour.