Jennifer Loveless MPH Karen Gibbs MSNMPH RN Objectives Identify the steps in the clinical standard development process at TCH Integrate recent evidence into practice EvidenceBased Practice ID: 933916
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Slide1
Improving Care Via Evidence-Based Clinical Standards
Jennifer Loveless, MPH
Karen Gibbs, MSN/MPH, RN
Slide2Objectives
Identify the steps in the clinical standard development process at TCH
Integrate recent evidence into practice
Slide3Evidence-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)
Slide4Clinical 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.
Slide5Evidence-Based Outcomes Center
Andrea Jackson, MBA, RN
EBP Specialist
Jennifer Loveless, MPH
EBP Specialist
Karen Gibbs, MSN/MPH, RN
EBP Specialist
Binita Patel, MD
Anne Dykes, RN, MSN, ACNS-BC
Assistant Director of EBOC
Sheesha Porter, MSN, RN
EBP Specialist
Christina Davidson, MD
Betsy Lewis, MSN, RN, CNL
EBP Specialist
Monica Lopez, MD
Slide6Examples of EBOC Products
Guideline comparison table
Care Guideline
Literature appraisal with GRADE table
AlgorithmClinical Decision SupportInterdisciplinary Plans of Care
Slide7Clinical Standard Development Process
Slide8Where to find documents…
Slide9Slide10Slide11Where to find documents…
TCH Clinical Standards are also available externally on the internet:
https://www.texaschildrens.org/departments/safety-outcomes/clinical-standards
Slide12Diabetic Ketoacidosis
Update of the original guideline from 2009
Major changes:
Fluids for resuscitation
changed from LR to 0.9% normal salineMannitol as the preferred agent for cerebral edema (hypertonic saline to be given as second line if mannitol is unavailable)
Slide13Acute 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
Slide14Kawasaki 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
Slide15Severe 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).
Slide16Treatment 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 CompazineAdditional Treatment for Continued HeadacheSodium Valproate Continued Headache After First Line TherapyDihydroergotamine (DHE) ProtocolRecommendation for the use of dexamethasone to prevent rebound headache
Slide17Sodium 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.
Slide18Suspected 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.
Slide19Status 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 TherapyFosphenytoinLevetiracetam (If patient has a history of cardiac disease, hemodynamically unstable, allergy to fosphenytoin)Refractory TherapyContinuous Midazolam InfusionPhenobarbital (If continuous midazolam infusion not available)
Slide20Acute 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. PRNRevised verbiage for referralsThis guideline is associated with a formal implementation team (Care Process Team)
Slide21Pneumonia
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 hospitalsAdded a recommendation against the use of procalcitonin to determine whether to initiate antibiotic therapyCombined the mild and moderate arms on the algorithmThis guideline is associated with a formal implementation team (Care Process Team)
Slide22Brief 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) collaborativeAdded a recommendation to not start acid suppression pharmacotherapy in patients with gastroesophageal reflux related BRUEAdded consideration for ECG or ECHO if cardiac etiology is suspectedAdded consults for multiple services
Slide23Currently In Progress
Pediatric Early Warning Systems
Acute Hematogenous Osteomyelitis and/or Septic Arthritis *update
Acute Otitis Media *update
Arterial Thrombosis *updateVenous Thrombosis *updateInfection Prevention in the Neutropenic PatientCentral Line-Associated Blood Stream Infection Prevention *updateTonsillectomy & Adenoidectomy *updateFever Without Localizing Signs (0-60 Days) *updateFever Without Localizing Signs (2-36 months) *update
Slide24Questions?
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
Slide25Slide26References
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-standardsInstitute of Medicine (2011). Clinical Practice Guidelines We Can Trust.