International journal of evidence-based healthcare
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Int J Evid Based Healthc · Jun 2009
Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?
Aim Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings. ⋯ 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.
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Int J Evid Based Healthc · Jun 2009
The implementation of evidence-based practice for the prevention/management of post-operative nausea and vomiting.
Aim To bring the research evidence for the prevention/management of post-operative nausea and vomiting into clinical practice in the surgical services department of a community hospital. Methods Audit and feedback were used to lead organisational change at the project hospital. A team of key stakeholders was created and helped to bring change to the way post-operative nausea and vomiting was treated and managed at the institution. ⋯ Results There was a vast improvement in evidence-based practice following change management. Furthermore, post-operative nausea and vomiting decreased from 18% at the start to 5% nausea and 0% vomiting at the end. Conclusion Change management using audit and feedback is effective in changing organisational practice and in improving patient outcomes following surgery.
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Int J Evid Based Healthc · Mar 2009
The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: a systematic review.
Background The increasing cost of healthcare in Australia demands changes in the way healthcare is delivered. Nurse practitioners have been introduced into specialty areas including emergency departments. Specific interventions are known to include the treatment and management of minor injuries, but little has been reported on their work. ⋯ Evidence comparing the clinical effectiveness of nurse practitioners to mainstream management of minor injuries was fair to poor methodological quality. When comparable data were pooled, there were no significant differences (P < 0.05) between nurse practitioners and junior doctors. Conclusions The results emphasise the need for more high-quality research using appropriate outcome measures in the area of clinical effectiveness of nurse practitioners, particularly interventions that improve outcomes for presentations to emergency departments and address issues of waiting and congestion.
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Int J Evid Based Healthc · Dec 2008
Systematic review of the effectiveness of nursing interventions in reducing or relieving post-operative pain.
Objectives The primary objective of this systematic review was to assess the effectiveness of nursing interventions for the relief/reduction of post-operative pain when compared with either standard care or other nursing interventions. Inclusion criteria Types of studies This review included randomised controlled trials (RCTs) and other quasi-randomised experimental research designs. Types of participants Adults treated for post-operative pain in an acute care hospital. ⋯ When there are two similarly effective interventions nurses need to weigh the possible positive and negative of the intervention including side effects, risk of adverse events, cost and patient preference. Other considerations include variations in patients' past pain experiences, type of surgery, many different analgesics. Although there were no controlled trials to support assessment and documentation, professionally and legally, documentation is required.
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Int J Evid Based Healthc · Dec 2008
The clinical effectiveness of length of bed rest for patients recovering from trans-femoral diagnostic cardiac catheterisation.
Background Cardiac catheterisation plays a vital role in the diagnosis and evaluation of cardiac conditions. The goal of management of patients after cardiac catheterisation is to reduce the risk of development of any local or prolonged vascular complications, in particular bleeding and haematoma formation at the puncture site. Bed rest and immobilisation of the affected leg are recommended practices to ensure adequate haemostasis at the femoral arterial puncture site and prevent complications. ⋯ However, there is evidence of benefit relating to decreased incidence and severity of back pain and cost-effectiveness following 3 h of bed rest. There is suggestive but inconclusive evidence of a benefit from bed rest for 2 h following trans-femoral cardiac catheterisation. Clinicians should consider a balance between avoiding increased risk of haematoma formation following 2-2.5 h of bed rest and circumventing back pain following more than 4 h of bed rest.