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Improving Care Via Evidence-Based Clinical Standards

Improving Care Via Evidence-Based Clinical Standards. Jennifer Loveless, MPH Karen Gibbs, MSN/MPH, RN. Objectives. Identify the steps in the clinical standard development process at TCH Integrate recent evidence into practice. Evidence-Based Practice.

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Improving Care Via Evidence-Based Clinical Standards

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  1. Improving Care Via Evidence-Based Clinical Standards Jennifer Loveless, MPH Karen Gibbs, MSN/MPH, RN

  2. Objectives • Identify the steps in the clinical standard development process at TCH • Integrate recent evidence into practice

  3. Evidence-Based Practice The conscientious and judicious use of current best evidence from clinical care research integrated with clinical expertise and patient values in making health care decisions. –Sackett et al. (1996) Image from Satterfield et al. (2009)

  4. Clinical Practice:Guidelines, Summaries, and Pathways Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. Rather than dictating a one-size-fits-all approach to patient care, clinical practice guidelines offer an evaluation of the quality of the relevant scientific literature and an assessment of the likely benefits and harms of a particular treatment. This information enables healthcare providers to proceed accordingly, selecting the best care for a unique patient based on his or her preferences. Institute of Medicine (2011). Clinical Practice Guidelines We Can Trust.

  5. Evidence-Based Outcomes Center Binita Patel, MD Christina Davidson, MD Monica Lopez, MD Anne Dykes, RN, MSN, ACNS-BC Assistant Director of EBOC Karen Gibbs, MSN/MPH, RN EBP Specialist Jennifer Loveless, MPH EBP Specialist Andrea Jackson, MBA, RN EBP Specialist Sheesha Porter, MSN, RN EBP Specialist Betsy Lewis, MSN, RN, CNL EBP Specialist

  6. Examples of EBOC Products • Guideline comparison table • Care Guideline • Literature appraisal with GRADE table • Algorithm • Clinical Decision Support • Interdisciplinary Plans of Care

  7. Clinical Standard Development Process

  8. Where to find documents…

  9. Where to find documents… TCH Clinical Standards are also available externally on the internet: https://www.texaschildrens.org/departments/safety-outcomes/clinical-standards

  10. Diabetic Ketoacidosis • Update of the original guideline from 2009 • Major changes: • Fluids for resuscitation  changed from LR to 0.9% normal saline • Mannitol as the preferred agent for cerebral edema (hypertonic saline to be given as second line if mannitol is unavailable)

  11. Acute Ischemic Stroke • Update to existing guideline • Standardization of assessment and diagnosis of acute arterial ischemic stroke in children, and initial treatment during the first 72 hours of symptom onset • Recommendations and diagnosis algorithm provide directions for providers on appropriate diagnostic testing for acute arterial ischemic stroke • Recommendations and management algorithm provide guidance for the use of thrombolytic therapy  in the pediatric population

  12. Kawasaki Disease • New diagnosis and management guideline and algorithms for the treatment of Kawasaki disease (KD) (older summaries archived) • Diagnostic criteria for the diagnosis of complete and incomplete KD • Guidance on when to perform echocardiogram for the detection of coronary artery aneurysms in complete and incomplete KD • Recommendations for the initial treatment of complete and incomplete KD (IVIG, aspirin, steroids, etc...) • Recommendations and guidance for the treatment of high risk KD patients

  13. Severe Traumatic Brain Injury • Update of the original guideline from 2018 • Changed the recommended bolus dose of Hypertonic Saline for the treatment of intracranial pressure from 6.5-10 mL/kg to 2-5 mL/kg (adapted from the Brain Trauma Foundation's new guideline recommendation).

  14. Treatment of Migraine Headaches in the Pediatric Emergency Center • Update of a previous Evidence-Based Practice Course summary from 2014 • Standardized tiered treatment for migraines  • Headache Cocktail • Ketorolac then Compazine • Additional Treatment for Continued Headache • Sodium Valproate  • Continued Headache After First Line Therapy • Dihydroergotamine (DHE) Protocol • Recommendation for the use of dexamethasone to prevent rebound headache

  15. Sodium Content in IV Fluids • New evidence summary finalized in August 2018 • Evidence summary recommending 0.9% sodium chloride as the sodium content for initial IV fluids in previously healthy pediatric patients.   • Patients that may need a different sodium content include neonates, renal patients, sickle cell patients, ICU patients, and other diagnoses that inhibit electrolyte regulation. 

  16. Suspected Child Physical Abuse • Update of the original guideline from 2011 • Standardization of initial assessment and consultations for patients 0 – 36 months with suspected child physical abuse • Expanded inclusion criteria age to 36 months (original age 24 months) • Recommendations for skeletal survey, head CT, fundoscopic retinal exam, abdominal CT and lab tests based upon patient age and clinical criteria.

  17. Status Epilepticus • July 2018 update of the original guideline from 2009 • Standardization of medication tiers for seizing patients. • Initial Therapy  • Lorazepam (IV Access) • Intranasal Midazolam (No IV Access) • Urgent Therapy • Fosphenytoin • Levetiracetam (If patient has a history of cardiac disease, hemodynamically unstable, allergy to fosphenytoin) • Refractory Therapy • Continuous Midazolam Infusion • Phenobarbital (If continuous midazolam infusion not available) 

  18. Acute Asthma Exacerbations  • January 2019 update of the guideline, which was last updated in 2014 and revised in 2017 • Major changes: • Added remarks to the steroid recommendation: For children with a recent (within 1-2 weeks) course of steroids, history of ICU admission, or severe persistent asthma, consider a longer course of oral steroids for asthma exacerbations. IV for PO dexamethasone solution is not available in outpatient pharmacies.  • Added a recommendation for magnesium dosing (to use standard-dose magnesium infusion vs. high-dose) • Revised RAMP to reflect a 'maximum' wean of q4H albuterol dosing vs. PRN • Revised verbiage for referrals • This guideline is associated with a formal implementation team (Care Process Team)

  19. Pneumonia • August 2018 update of the guideline, which was last updated in January 2013 • Major changes: • Modified the recommendation on macrolides to recommend against their routine use and to provide info on when to consider their use This recommendation was changed based on PHIS data that showed our macrolide use at TCH was higher than that of our peer hospitals • Added a recommendation against the use of procalcitonin to determine whether to initiate antibiotic therapy • Combined the mild and moderate arms on the algorithm • This guideline is associated with a formal implementation team (Care Process Team)

  20. Brief Resolved Unexplained Event (BRUE)formerly Apparent Life-Threatening Event (ALTE)  • February 2019 update of the guideline, which was originally completed in July 2015 (began as an Evidence-Based Practice Course topic) • Major changes: • Incorporated the AAP's 2016 guideline and 2 guidelines from other children's hospitals that were developed via the Pediatric Initiative for Clinical Standards (PICS) collaborative • Added a recommendation to not start acid suppression pharmacotherapy in patients with gastroesophageal reflux related BRUE • Added consideration for ECG or ECHO if cardiac etiology is suspected • Added consults for multiple services

  21. Currently In Progress • Pediatric Early Warning Systems  • Acute Hematogenous Osteomyelitis and/or Septic Arthritis *update • Acute Otitis Media *update • Arterial Thrombosis *update • Venous Thrombosis *update • Infection Prevention in the Neutropenic Patient • Central Line-Associated Blood Stream Infection Prevention *update • Tonsillectomy & Adenoidectomy *update • Fever Without Localizing Signs (0-60 Days) *update • Fever Without Localizing Signs (2-36 months) *update

  22. Questions? If you’re interested in observing a content expert team or have any comments, questions, or suggestions about any of the EBOC products, e-mail us at: eboc@texaschildrens.org

  23. References • Hultcrantz, M., Rind, D., Akl, E. A., Treweek, S., Mustafa, R. A., Iorio, A., et al. (2017). The GRADE Working Group clarifies the construct of certainty of evidence. Journal of Clinical Epidemiology, 87, 3-13.  • Schunemann, H., Brozek, J., Guyatt, G., & Oxman, A. (Eds.). (2013). GRADE Handbook. Retrieved from https://gdt.gradepro.org/app/handbook/handbook.html.  • Evidence-Based Outcomes Center. (n.d.). Texas Children’s Hospital Clinical Standards. Retrieved from https://www.texaschildrens.org/departments/safety-outcomes/clinical-standards • Institute of Medicine (2011). Clinical Practice Guidelines We Can Trust.

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