Certain structural limitations within the field, such as worker shortages in the face of increasing public demands and the reliance of the field on trainees such as students, interns, and residents, create other hurdles. The authors conclude by suggesting a two-tiered system of healthcare whereby ultrasafety could be more easily accomplished in areas of medicine considered more stable (first tier), and a second tier of care that would include the more unstable conditions, and thus inherently, represent the higher risk situations where errors are more likely to occur.
Another provocative point of this article is the need to move toward educating and training teams—not individuals.
The Importance of Implementing COPD Guidelines
Harvey PA, Murphy MC, Dornom E, et al. Implementing evidence-based guidelines: inpatient management of chronic obstructive pulmonary disease. Intern Med J. 2005;35:151-155.
COPD is a common diagnosis that sometimes requires hospitalization. Evidence-based guidelines for disease management, including that of hospitalized patients, exist, but there is a paucity of knowledge about the actual quality of care delivered in the hospital as it aligns with published guidelines. This study by Harvey, et al. explores the quality of care delivered in the hospital for patients with COPD, while at the same time investigating an intervention for the medical staff in an effort to improve adherence to evidenced-based guidelines of the disease.
Using ICD-10 codes for a COPD diagnosis, the study incorporated a retrospective chart review of 49 hospital admissions prior to the intervention and 35 admissions after the intervention in a hospital in Melbourne, Australia. Data were collected pertaining to the hospital management of COPD as it compared with what the authors considered to be Level A—or the highest level of evidence summarized from several professional organizations. The intervention delivered to the medical staff included a summarized presentation of the results from the initial audit of the 49 charts, as well as an educational package that was given to them following the presentation.
Except for inappropriate use of intravenous aminophylline, of which there was a 100% concordance to Level A guidelines, the initiation of systemic steroids (intravenous and/or oral) had the highest concordance rate of 80% and 83%, pre- and postintervention respectively. Appropriate steroid duration (seven to 14 days) had the lowest concordance rates at 10% and 29%, pre- and postintervention respectively.
In addition, preintervention concordance (10%) involving steroid duration was the only rate considered significantly different in the postintervention group (29%). While concordance rates were high for the use of any type of nebulized bronchodilator (96% preintervention and 80% postintervention), the Level A guidelines the authors used suggested that beta-agonist bronchodilators should be used alone prior to the initiation of ipratropium bromide. The concordance rates for this guideline were 27% preintervention and 34% postintervention.
Largely, the authors felt their intervention failed to improve concordance rates to the Level A guidelines investigated and also that their findings of variable and lower concordance rates across the board corroborated other similar studies. The major weaknesses of this study included the small sample size and the nonrandomness of the sampling.
In addition, the authors report that the particular hospital studied included junior doctors who rotated on and off service, which likely prevented the effects of the intervention from being measured on a provider level. In spite of the weaknesses in the study, the article brings to light the need for a more effective translation of evidence-based guidelines to actual practice, especially in the practice of COPD management in the hospital. Further methods of guideline implementation in the clinic setting must be elucidated to improve the care patients with COPD receive in the hospital.