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Background: Clinical practice guidelines are systematically developed statements intended to optimize patient care. However, a gapless implementation of guideline recommendations requires health care personnel not only to be aware of the recommendations and to support their content but also to recognize every situation in which they are applicable. To not miss situations in which recommendations should be applied, computerized clinical decision support can be provided through a system that allows an automated monitoring of adherence to clinical guideline recommendations in individual patients.
Objective: This study aims to collect and analyze the requirements for a system that allows the monitoring of adherence to evidence-based clinical guideline recommendations in individual patients and, based on these requirements, to design and implement a software prototype that integrates guideline recommendations with individual patient data, and to demonstrate the prototype’s utility in treatment recommendations.
Methods: We performed a work process analysis with experienced intensive care clinicians to develop a conceptual model of how to support guideline adherence monitoring in clinical routine and identified which steps in the model could be supported electronically. We then identified the core requirements of a software system to support recommendation adherence monitoring in a consensus-based requirements analysis within the loosely structured focus group work of key stakeholders (clinicians, guideline developers, health data engineers, and software developers). On the basis of these requirements, we designed and implemented a modular system architecture. To demonstrate its utility, we applied the prototype to monitor adherence to a COVID-19 treatment recommendation using clinical data from a large European university hospital.
Results: We designed a system that integrates guideline recommendations with real-time clinical data to evaluate individual guideline recommendation adherence and developed a functional prototype. The needs analysis with clinical staff resulted in a flowchart describing the work process of how adherence to recommendations should be monitored. Four core requirements were identified: the ability to decide whether a recommendation is applicable and implemented for a specific patient, the ability to integrate clinical data from different data formats and data structures, the ability to display raw patient data, and the use of a Fast Healthcare Interoperability Resources–based format for the representation of clinical practice guidelines to provide an interoperable, standards-based guideline recommendation exchange format.
Conclusions: Our system has advantages in terms of individual patient treatment and quality management in hospitals. However, further studies are needed to measure its impact on patient outcomes and evaluate its resource effectiveness in different clinical settings. We specified a modular software architecture that allows experts from different fields to work independently and focus on their area of expertise. We have released the source code of our system under an open-source license and invite for collaborative further development of the system.
Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial
(2022)
Importance: A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements.
Objective: To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone.
Design, Setting, and Participants: This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019.
Interventions: In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles.
Main Outcomes and Measures: The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain.
Results: A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups.
Conclusions and Relevance: Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery.
Background
Dispatching first responders (FR) to out-of-hospital cardiac arrest in addition to the emergency medical service has shown to increase survival. The promising development of FR systems over the past years has been challenged by the outbreak of COVID-19. Whilst increased numbers and worse outcomes of cardiac arrests during the pandemic suggest a need for expansion of FR schemes, appropriate risk management is required to protect first responders and patients from contracting COVID-19. This study investigated how European FR schemes were affected by the pandemic and what measures were taken to protect patients and responders from COVID-19.
Methods
To identify FR schemes in Europe we conducted a literature search and a web search. The schemes were contacted and invited to answer an online questionnaire during the second wave of the pandemic (December 2020/ January 2021) in Europe.
Results
We have identified 135 FR schemes in 28 countries and included responses from 47 FR schemes in 16 countries. 25 schemes reported deactivation due to COVID-19 at some point, whilst 22 schemes continued to operate throughout the pandemic. 39 schemes communicated a pandemic-specific algorithm to their first responders. Before the COVID-19 outbreak 20 FR systems did not provide any personal protective equipment (PPE). After the outbreak 19 schemes still did not provide any PPE. The majority of schemes experienced falling numbers of accepted call outs and decreasing registrations of new volunteers. Six schemes reported of FR having contracted COVID-19 on a mission.
Conclusions
European FR schemes were considerably affected by the pandemic and exhibited a range of responses to protect patients and responders. Overall, FR schemes saw a decrease in activity, which was in stark contrast to the high demand caused by the increased incidence and mortality of OHCA during the pandemic. Given the important role FR play in the chain of survival, a balanced approach upholding the safety of patients and responders should be sought to keep FR schemes operational
Purpose
Due to the demographic change morbidity raises the demand for medical hospital services as well as a need for medical specialization, while economic and human resources are diminishing. Unlike other industries hospitals do not have sufficient data and adequate models to relate growing demands and increasing performance to growth in staff capacity and to increase in staff competences.
Method
Based on huge medical data sample covering the years from 2010 to 2014 with more than 150,000 operations of the Department for Anesthesiology at the University Hospital Muenster, Germany, comparisons are drawn between the development of medical services and the development of personnel capacity and expertise.
Results
The numbers of surgical operations increased by 21% and “skin incision to closure” time by 17%. Simultaneously, personnel capacity grew by 16% largely resting upon recruiting first-time employees. Expertise measured as “years of professional experience” dwindled from 10 years to 5.4 years on average and staff turnover accelerated.
Conclusion
Static benchmark data collected at fixed reference dates do not sufficiently reflect the nexus between capacity and competence and do not reflect the dynamic changes in a hospital’s requirements for expertise and specialization, at all. Staff turnover leads to a loss of experience, which jeopardizes patient safety and hampers medical specialization. In consequence of the dramatic shortage of medical specialists, drop-off rates must be reduced and retention rates must be increased. To that end, working conditions need to be fundamentally converted for a multigeneration, multicultural, and increasingly female workforce.
Background: To determine the suitability of different superimposed high-frequency jet ventilation (SHFJV) application methods during tracheal bleeding. Objective: To determine the effect of SHFJV on the aspiration of blood during tracheal bleeding. Methods: A test lung was ventilated using SHFJV via a rigid endoscope, a jet laryngoscope and a 4-lumen jet catheter. Packed red blood cells (PRBCs) were injected into the artificial trachea caudally to the rigid endoscope and jet laryngoscope ventilation, and both caudally and cranially during ventilation via the 4-lumen jet catheter, and the migration of PRBCs during ventilation was studied using continuous video recording. Results: Migration of blood into the lower respiratory tract did not occur during SHFJV via the rigid endoscope and jet laryngoscope and via the 4-lumen jet catheter with the bleeding caudal to ventilation source. If the bleeding was cranial to the 4-lumen jet catheter ventilation, migration of blood into the lower respiratory tract was seen when reflux of blood reached the entrainment area. From this area, blood is transported within the jet stream into the lower respiratory tract. Conclusions: SHFJV protects the lower respiratory tract from blood aspiration in case of tracheal bleeding. During SHFJV via the 4-lumen jet catheter, aspiration of blood only occurs if bleeding is localized cranial to the 4-lumen jet catheter ventilation. In case of heavy tracheal bleeding, the jet sources should be positioned cranial to the site of bleeding.