Development and prioritisation of policy recommendations for medication safety improvement for intensive care units: a European Association of Hospital Pharmacists Special Interest Group Delphi Study

OBJECTIVES

Medication errors (MEs) are a leading cause of morbidity and mortality in the healthcare system. Patients admitted to intensive care units (ICUs) are potentially more susceptible to MEs due to severity of illness, the complexity of treatments they receive and the challenging nature of the ICU setting. The European Association of Hospital Pharmacists established a Special Interest Group (SIG) to undertake a programme of work to develop and prioritise recommendations to support medication safety improvement in ICUs across Europe.

METHODS

Initial policy recommendations for medication safety within the ICU environment were developed following reviews of the literature and engagement with relevant stakeholders. A Delphi panel of 21 members of the SIG, that comprised healthcare professionals (HCPs) with expertise in ICU and/or medication safety, was convened in 2022. We conducted two rounds using a modified Delphi technique whereby participants anonymously ranked on a 9-point Likert Scale the policy recommendations according to their priority for implementation.

RESULTS

In total, 32 policy recommendations were developed. In Delphi Round 1, 19 HCPs participated; consensus was achieved on most recommendations and partial consensus on six. In Delphi Round 2, 18 HCPs participated. After two Delphi rounds, consensus was achieved on all 32 recommendations. All recommendations were considered 'high priority' except one that was considered 'medium priority'.

CONCLUSIONS

Through this study it was possible to develop and prioritise evidence-based policy recommendations to enhance medication safety, which may contribute to reducing MEs in ICUs across Europe. All recommendations were considered 'high priority' for implementation except one, indicating the perceived value of these recommendations in improving medication safety through preventing MEs in ICUs.

Ten-Year Follow-Up of Women at High Risk for Familial Breast and Ovarian Cancer in Otago and Southland, New Zealand

BACKGROUND

Care for families affected by Familial Breast and Ovarian Cancer (FBOC) is challenging as a broad range of professions and specialties are involved. The aim was to review management and outcomes for a cohort of women at high risk for familial breast and ovarian cancer.

METHODS

Ten-year retrospective follow-up study of individuals in Southern New Zealand  assessed by Genetic Health Service New Zealand to be high risk for FBOC and without a personal cancer diagnosis at time of consultation.

RESULTS

Twenty women were identified; twelve underwent genetic testing, and a pathogenic BRCA variant was identified in eleven. Eight women had no testing, as no index case was available. Guidelines had been fully adhered to in 55% of women, regardless of BRCA status. Six did not undergo appropriate breast surveillance. To date, seven of the 11 patients who tested positive for a pathogenic BRCA variant (64%) had risk-reducing surgeries. Two women were diagnosed with breast cancer on surveillance imaging; none were diagnosed with ovarian cancer. Four women were lost to follow-up, one of whom subsequently presented with a symptomatic breast cancer.

CONCLUSIONS

To our knowledge, this is the first study providing long-term data for FBOC in New Zealand. Overall, guidelines were followed satisfactorily, but some women did not receive appropriate surveillance or referrals. An integrated interdisciplinary long-term care provision model in New Zealand might help to address gaps in FBOC surveillance and management.

Trustworthy evidence-based versus untrustworthy guidelines: detecting the difference

Guidelines are essential tools in healthcare decision-making. Trustworthy guidelines inform clinicians not only on the direction (against or in favour) and strength (strong or weak/conditional) of recommendations but also on the certainty of the underlying evidence. Developing trustworthy guidelines requires panellists with clinical and methodological expertise who consider patients' values and preferences. Adherence to trustworthiness standards remains variable; clinicians should, therefore, be able to distinguish trustworthy from untrustworthy guidelines. In this paper, we offer eight domains of disparities between trustworthy evidence-based guidelines and less trustworthy guidelines.

Two Years of Experience and Methodology of Korean COVID-19 Living Clinical Practice Guideline Development

BACKGROUND

In Korea, during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, we responded to the uncertainty of treatments under various conditions, consistently playing catch up with the speed of evidence updates. Therefore, there was high demand for national-level evidence-based clinical practice guidelines for clinicians in a timely manner. We developed evidence-based and updated living recommendations for clinicians through a transparent development process and multidisciplinary expert collaboration.

METHODS

The National Evidence-based Healthcare Collaborating Agency (NECA) and the Korean Academy of Medical Sciences (KAMS) collaborated to develop trustworthy Korean living guidelines. The NECA-supported methodological sections and 8 professional medical societies of the KAMS worked with clinical experts, and 31 clinicians were involved annually. We developed a total of 35 clinical questions, including medications, respiratory/critical care, pediatric care, emergency care, diagnostic tests, and radiological examinations.

RESULTS

An evidence-based search for treatments began in March 2021 and monthly updates were performed. It was expanded to other areas, and the search interval was organized by a steering committee owing to priority changes. Evidence synthesis and recommendation review was performed by researchers, and living recommendations were updated within 3-4 months.

CONCLUSION

We provided timely recommendations on living schemes and disseminated them to the public, policymakers and various stakeholders using webpages and social media. Although the output was successful, there were some limitations. The rigor of development issues, urgent timelines for public dissemination, education for new developers, and spread of several new COVID-19 variants have worked as barriers. Therefore, we must prepare systematic processes and funding for future pandemics.

Modeling Clinical Guidelines for an Epilepsy-CDSS: The EDiTh Project

The knowledge transformation process involves the guideline for the diagnosis and therapy of epilepsy to an executable and computable knowledge base that serves as the basis for a decision-support system. We present a transparent knowledge representation model which facilitates technical implementation and verification. Knowledge is represented in a plain table, used in the frontend code of the software where simple reasoning is performed. The simple structure is sufficient and comprehensible also for non-technical persons (i.e., clinicians).

Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry

Background

Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings.

Objective

To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE.

Methods

Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset.

Results

Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively).

Conclusion

The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.

NCPDP recommendations for standardizing dosing in metric units (mL) on prescription container labels of oral liquid medications, version 2.0

PURPOSE

Best practices and guidance are provided for standardizing dosing instructions on prescription container labels of oral liquid medications by eliminating use of U.S. customary (household) units and adopting metric units universally, with the goal of decreasing the potential for error and improving safety and outcomes when patients and caregivers take and administer these medications.

SUMMARY

Despite decades of best practice use of metric units in organized healthcare settings and advocacy by various professional societies, medication safety experts, and standards setting organizations, use of household units (e.g., teaspoon) on prescription container labeling instructions for oral liquid medications persists in community pharmacy settings. Five years after publication of the National Council for Prescription Drug Programs' (NCPDP's) original white paper advocating metric-only dosing, very few community pharmacy companies appear to require oral liquid dosing instructions be presented in metric-only units (mL). Error-prone dosing designations contribute to medication errors and patient harm. Use of both multiple volumetric units (e.g., teaspoonsful, tablespoonsful) and multiple abbreviations for the same volumetric units (e.g., mL, cc, mls; tsp, TSP, t) increases the likelihood of dosing errors. Opportunities for error exist with each administration of an oral liquid medication and, unless coordinated with dispensing of appropriate oral dosing devices and optimal counseling, can result in use of household utensils (e.g., uncalibrated teaspoons) or discordantly marked devices that can further exacerbate the risk of error. Since publication of NCPDP's original white paper, new standards have been adopted governing official liquid volume representation, calibrated dosing devices, and e-prescribing software which support the elimination of non-metric units to reduce use of dosing practices that are error-prone. In each case, U.S. customary (household) units have been eliminated in official standards and certification requirements. Therefore, use of non-metric units for oral dosing of liquid medications no longer is an acceptable practice.

CONCLUSION

Key factors contributing to dosing errors with oral liquid medications include use of multiple volumetric units and abbreviations; failure to institute policies and procedures that eliminate the use of non-metric (e.g., household) units and universally adopt metric-only dosing instructions in all settings; failure to coordinate dosing instructions with dosing device markings, appropriate type (oral syringe versus cup), and optimal volumes (e.g., 1-, 5-, or 10-mL devices); failure to adequately counsel patients about appropriate measurement and administration of oral liquid medication doses; and use or error-prone practices such as missing leading zeros and elimination of trailing zeros in prescriptions and container labels. Adoption of this white paper's recommendations will align dosing designations for oral liquid medications in all settings with current standards and attain universal metric-only practice.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

Consensus Recommendations of the Multiple Sclerosis Study Group and the Portuguese Neuroradiological Society for the Use of Magnetic Resonance Imaging in Multiple Sclerosis in Clinical Practice: Part 2

INTRODUCTION

Magnetic resonance imaging is recognized as the most important diagnostic test in the diagnosis of multiple sclerosis, differential diagnosis and evaluation of progression/therapeutic response. However, to make optimal use of magnetic resonance imaging in multiple sclerosis, the use of a standard, reproducible and comparable imaging protocol is of uttermost importance. In this context, the Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. This document represents the second part of the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice.

MATERIAL AND METHODS

The Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after discussing the topic in national meetings and after a working group meeting held in Figueira da Foz, May 2017, appointed a committee of experts that have developed several standard protocols on the use of magnetic resonance imaging on multiple sclerosis by consensus. The document obtained was based on the best scientific evidence and expert opinion. Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Standardized strategies of magnetic resonance imaging referral in clinical practice for diagnosis and follow-up of multiple sclerosis were published in the first part of this paper.

RESULTS

We provide magnetic resonance imaging acquisition protocols regarding multiple sclerosis diagnostic and monitoring and the information to be included in the report for application across Portuguese healthcare institutions.

CONCLUSION

We hope that these first Portuguese magnetic resonance imaging guidelines will contribute to optimize multiple sclerosis management and improve patient care in Portugal.

Guideline Clearinghouse Is Dead. Long Live the Guideline Clearinghouse?

The National Guidelines Clearinghouse might be making a comeback. It's been contracted out to the ECRI Institute, a not-for-profit organization that conducts medical safety research. ECRI plans to have a version of the clearinghouse website up and running anytime soon, with plans for a full relaunch in 2019.

Blood Sugar Control Limbo: How Low To Go?

The stakes are particularly high when interpretations differ on evidence for treating diabetes, a condition affecting 30 million Americans and costing $245 billion annually. New guidelines from the American College of Physicians recommend less stringent blood sugar targets for most people with diabetes. Other professional groups think that's a terrible idea.

Consensus Recommendations of the Multiple Sclerosis Study Group and Portuguese Neuroradiological Society for the Use of the Magnetic Resonance Imaging in Multiple Sclerosis in Clinical Practice: Part 1

INTRODUCTION

Magnetic resonance imaging is established as a recognizable tool in the diagnosis and monitoring of multiple sclerosis patients. In the present, among multiple sclerosis centers, there are different magnetic resonance imaging sequences and protocols used to study multiple sclerosis that may hamper the optimal use of magnetic resonance imaging in multiple sclerosis. In this context, the Group of Studies of Multiple Sclerosis and the Portuguese Society of Neuroradiology, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. The purpose of this document is to publish the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice.

MATERIAL AND METHODS

The Group of Studies of Multiple Sclerosis and the Portuguese Society of Neuroradiology, after discussion of the topic in national meetings and after a working group meeting held in Figueira da Foz on May 2017, have appointed a committee of experts that have developed by consensus several standard protocols on the use of magnetic resonance imaging in the diagnosis and follow-up of multiple sclerosis. The document obtained was based on the best scientific evidence and expert opinion. Subsequently, the majority of Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Technical magnetic resonance imaging protocols regarding diagnostic, monitoring and the recommended information to be included in the magnetic resonance imaging report will be published in a separate paper.

RESULTS

We provide some practical guidelines to promote standardized strategies to be applied in the clinical practice setting of Portuguese healthcare professionals regarding the use of magnetic resonance imaging in multiple sclerosis.

CONCLUSION

We hope that these first Portuguese magnetic resonance imaging guidelines, based in the best available clinical evidence and practices, will serve to optimize multiple sclerosis management and improve multiple sclerosis patient care across Portugal.

Non-prescription dispensing of emergency oral contraceptives: Recommendations from the German Federal Chamber of Pharmacists [Bundesapothekerkammer]

BACKGROUND

Emergency hormonal contraceptives (EHC) are contraceptives used to prevent unintended pregnancy following unprotected sexual intercourse (USI) or contraceptive failure. The EHCs available without a prescription include medicines containing levonorgestrel (LNG) in more than 80 countries and, recently, based on an EU-switch ellaOne®, which contains ulipristal acetate (UPA). EHCs work by stopping or delaying ovulation. Those containing LNG can be used up to 72 hours after USI or contraceptive failure, while UPA can be used up to 120 hours. In the context of the UPA implementation process, Germany switched LNG to non-prescription status as well.

OBJECTIVES

To develop recommendations, a protocol, and a continuing education program for pharmacists to assure quality when giving advice and dispensing EHCs in community pharmacies without a medical prescription.

METHODS

The recommendations were developed by an iterative process of drafting, recognizing, and discussing comments and proposals for amendments as well a seeking agreement with a number of stakeholders such as the Federal Ministry of Health (BMG), Federal Institute for Drugs and Medical Devices (BfArM), Federal Chamber of Physicians (BÄK), Drug Commission of German Physicians (AkdÄ), professional organizations/associations of gynaecologists, pharmaceutical OTC-industry as well as government-controlled, private, and church-based organizations and centres providing advice on sex education and family planning.

RESULTS

The recommendations were eventually endorsed by the BMG in consultation with the BfArM.

CONCLUSIONS

The recommendations were made public, published in the professional journal and used in an uncounted number of continuing education programs based on the curriculum and provided by the State Chambers of Pharmacists.

[Quality of the Spanish Clinical Guidelines about Alzheimer's Disease and others Dementias]

BACKGROUND

The care of patients with Alzheimer's disease and other dementias has become a priority for healthcare systems. This is evidenced by the increasing number of clinical practice guidelines (CPG) developed in our country aimed to help professionals in making health decisions. The aim of our study was to evaluate the quality of the Spanish CPG on Alzheimer's disease and other dementias using the AGREE II instrument.

METHODS

Nine GPC were selected according to the inclusion criteria: Full GPC available; aimed to healthcare professionals; and published between 2002-2013. Two reviewers independently assessed the quality of the guides through the AGREE II instrument, in order to assess the methodological rigor and transparency of the GPC.

RESULTS

88.8% of the guides scored a very poor quality editorial independence. Respect to rigor in the development and clarity of presentation, 77.7% also scored very low quality. There is a guide that stands out for a score above 50% in all domains of the instrument.

CONCLUSIONS

The worst scored domains were Editorial independence, Rigor in the development and Applicability, in this order. The highest rated domains were Scope and Objectives and Clarity of Presentation. The guideline of the Ministry of Health, Social Policy and Equality is the best, obtaining a score above 50% in all domains. Overall, the quality of the 9 guidelines evaluated is low or very low, only two of them score as good overall quality.

Defining 'elderly' in clinical practice guidelines for pharmacotherapy

OBJECTIVE

To identify how 'elderly' patients are defined and considered within Australian clinical guidelines for the use of pharmacotherapy.

METHOD

Guidelines pertaining to the use of pharmacotherapy, focusing on conditions described in National Health Priority Areas, were identified using databases (Medline, Google Scholar) and organisation websites (Department of Health and Ageing, National Heart Foundation, National Health and Medical Research Council). Guidelines were reviewed and qualitatively analysed to identify any references or definitions of 'elderly' persons.

RESULTS

Among the 20 guidelines reviewed, 3 defined 'elderly' by chronological age (i.e., years since birth) while the remaining 17 guidelines did not define 'elderly' in any way. All 20 guidelines used the term 'elderly', whilst some guidelines provided age (chronological)-based dosage recommendations suggesting an ageist or generalist approach in their representation of 'elderly', for which rationale was seldom provided. Thematic analysis of the statements revealed five key themes regarding how 'elderly' was considered within the guidelines, broadly describing 'elderly' persons as being frail and with altered pharmacology. Some guidelines also highlighted the limited evidence base to direct clinical decision-making. A continuum of perceptions of ageing also emerged out of the identified themes.

CONCLUSION

Clinical practice guidelines currently do not adequately define 'elderly' persons and provide limited guidance on how to apply treatment recommendations to older persons. The representation of 'elderly' in guidelines needs to be less based on chronological age or generic definitions focusing more on establishing a direct link between an individual patient's characteristics and the pharmacology of their prescribed medication. Clinical guidelines that do not offer any practical descriptions of the features of ageing that are specifically related to the use of pharmacotherapy, or how to assess these in individual patients, render decision-making challenging.

Application of NHG guidelines in patients referred for stable chest pain syndromes

Purpose. Guidelines of the Dutch Association of General Practitioners (NHG) dictate the evaluation, treatment, and referral process of patients with stable chest pain syndromes (CPS). Adherence to this guideline was assessed in a consecutive group of patients referred to our hospital. Methods. We retrospectively studied the records of 296 subjects referred to our outpatient department in 2007 for evaluation of stable CPS. Referral letters were checked for completeness (past and present history, mentioning of risk factors for cardiovascular disease, physical examination, listing of medication) and used to judge adherence to the guideline. In a subset of patients, additional information regarding the referral process was gathered by telephone interview.Results. The referral letter was complete in only 67 patients (23%); items most often not reported were physical examination (63%) and cardiovascular risk factors (62%). Judging from the referral letter, 23 patients (8%) were evaluated in accordance with the NHG guideline prior to their referral. In patients in whom the final diagnosis of angina pectoris was made by the cardiologist, this was 20%. Seventy-nine patients were contacted by telephone after their work-up by the cardiologist; 36 of them (44%) reported being referred at their first visit to their primary physician, while 14 (18%) were referred at their own request.

CONCLUSION

Prior to referral, only a minority of patients with stable CPS were evaluated and treated in accordance with NHG guidelines. Furthermore, their referral letter was often incomplete. (Neth Heart J 2010;18:178-82.).