Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Evidence-based chronic heart-failure management programs : myth or reality?

Background Chronic heart-failure management programmes (CHF-MPs) have become part of standard care for patients with chronic heart failure (CHF). Objective To investigate whether programmes had applied evidence-based expert clinical guidelines to optimise patient outcomes. Design A prospective cross-sectional survey was used to conduct a national audit. Setting Community setting of CHF-MPs for patients postdischarge. Sample All CHF-MPs operating during 2005–2006 (n=55). Also 10–50 consecutive patients from 48 programmes were recruited (n=1157). Main outcome measures (1) Characteristics and interventions used within each CHF-MP; and (2) characteristics of patients enrolled into these programmes. Results Overall, there was a disproportionate distribution of CHF-MPs across Australia. Only 6.3% of hospitals nationally provided a CHF-MP. A total of 8000 postdischarge CHF patients (median: 126; IQR: 26–260) were managed via CHF-MPs, representing only 20% of the potential national case load. Significantly, 16% of the caseload comprised patients in functional New York Heart Association Class I with no evidence of these patients having had previous echocardiography to confirm a diagnosis of CHF. Heterogeneity of CHF-MPs in applied models of care was evident, with 70% of CHF-MPs offering a hybrid model (a combination of heart-failure outpatient clinics and home visits), 20% conducting home visits and 16% conducting an extended rehabilitation model of care. Less than half (44%) allowed heart-failure nurses to titrate medications. The main medications that were titrated in these programmes were diuretics (n=23, 96%), β-blockers (n=17, 71%), ACE inhibitors (ACEIs) (n=14, 58%) and spironolactone (n=9, 38%). Conclusion CHF-MPs are being implemented rapidly throughout Australia. However, many of these programmes do not adhere to expert clinical guidelines for the management of patients with CHF. This poor translation of evidence into practice highlights the inconsistency and questions the quality of health-related outcomes for these patients.

A role for workforce competencies in evidence-based health promotion education

Education programs should be based on research about the knowledge and skills required for practice, rather than on intuition or tradition, but there is limited published curriculum research on health promotion education. This paper describes a case study of how workforce competencies have been used to assist evidence-based health promotion education in the areas of curriculum design, selection of assessment tasks and continuous quality assurance processes in an undergraduate program at an Australian university. A curriculum-competency mapping process successfully identified gaps and areas of overlap in an existing program. Previously published health promotion workforce competencies were effectively used in the process of selecting assessment items, providing clear guidelines for curriculum revision and a useful method to objectively assess competency content in an evidence informed framework. These health promotion workforce competencies constituted an additional tool to assess course quality. We recommend other tertiary institutions consider curriculum-competency mapping and curriculum based assessment selection as quality and evidence based curriculum review strategies.

Evidence based drug therapy : are optimal doses and multiple medication therapies realistic in patients with chronic heart failure

Background: Chronic Heart Failure (CHF) has a high mortality and morbidity. Large scale randomised controlled trials have proven the benefits of beta blockade and ACE inhibitors in reducing mortality in patients with CHF and expert guidelines mandate their use. In spite of these recommendations, important therapies are under-prescribed and under-utilised.

Method: 1015 consecutive patients enrolled in CHF management programs across Australia were surveyed during 2005-2006 to determine prescribing patterns in heart failure medications. These patients were followed-up for a period of 6 months.

Results: The survey revealed that beta blockers were prescribed to 80% of patients (more than 85% were on sub-optimal doses) and 70% were prescribed Angiotensin converting enzyme (ACE) inhibitors (approximately 50% were on sub-optimal dose). 19% of patients were prescribed Angiotensin receptor blockers (ARBs). By 6 months <25% of the patients who were on sub-optimal dose beta blockers or ACE inhibitors at baseline, had been up-titrated to maximum dose (p<0.0001). In CHF programs, were nurses were able to titrate medications, 75% of patients reached optimal dose of beta blockers compared to those programs with no nurse-led medication titration, where only 25% of patients reached optimal dose (p<0.004). When examining optimal dosage for any two of these mandatory medications, less patients were on optimal therapy. Beta blockers and ACE inhibitors, were both prescribed in combination in 60% of patients. While beta blockers and ARBs were prescribed to 15% of patients.

Conclusion: Whilst prescribing rates for a single medication strategy of beta blockers, or ACE inhibitors were greater than 70%, an increase in dosage of these medications and utilisation of proven combination therapy of these medications was poor. It is suggested that clinical outcomes for this cohort of patients could be further improved by adherence to evidence-based practice, ESC guidelines, and optimisation of these medications by heart failure nurses in a CHF program. On the basis of these findings and in the absence of ready access to a polypill, focussing on evidence-based practice to increase utilisation and optimal dosage of combination medication therapy is critical.

Evidence based approaches to youth justice

This monograph was originally prepared as part of a review of services and programs offered in youth justice facilities in South Australia for the Office of the Guardian for Children andYoung People.

The NICHD protocol: a review of an internationally-used evidence-based tool for training child forensic interviewers

Purpose
– The purpose of this paper is to review an evidence-based tool for training child forensic interviewers called the National Institute of Child Health and Human Development Protocol (NICHD Protocol), with a specific focus on how the Protocol is being adapted in various countries.
Design/methodology/approach
– The authors include international contributions from experienced trainers, practitioners, and scientists, who are already using the Protocol or whose national or regional procedures have been directly influenced by the NICHD Protocol research (Canada, Finland, Israel, Japan, Korea, Norway, Portugal, Scotland, and USA). Throughout the review, these experts comment on: how and when the Protocol was adopted in their country; who uses it; training procedures; challenges to implementation and translation; and other pertinent aspects. The authors aim to further promote good interviewing practice by sharing the experiences of these international experts.
Findings
– The NICHD Protocol can be easily incorporated into existing training programs worldwide and is available for free. It was originally developed in English and Hebrew and is available in several other languages.
Originality/value
– This paper reviews an evidence-based tool for training child forensic interviewers called the NICHD Protocol. It has been extensively studied and reviewed over the past 20 years. This paper is unique in that it brings together practitioners who are actually responsible for training forensic interviewers and conducting forensic interviews from all around the world.

Preventing tobacco use and harm: what is evidence based policy?

The majority of tobacco users commence in early to mid-adolescence. Tobacco smoking can be characterised as a chronic, relapsing disorder. While risk increases with amount smoked, there is no safe level of use (i.e., all use is risky). Duration of use is the most important predictor of premature death with the majority of excess morbidity and mortality avoidable if people quit before middle age. Investment in initiatives that reduce smoking among pregnant women and those at risk of cardiovascular disease provide quickest returns -in reduced health care episodes and expenditure.  Measures that successfully reduce smoking among parents probably reduce smoking uptake by children, and high levels of smoking among both children and parents appear to be associated with higher levels of illicit drug use.
The evidence base for pharmcotherapies in the treatment of tobacco dependence is very strong. Population-level initiatives such as tax increases, mass media-led campaigns and smoke-free policies are all highly cost-effective in reducing population-smoking levels, including among children and young people.
Australian tobacco control initiatives have been based on "social ecology" conceptualisations of the problem, which acknowledge the pivotal role of the media in shaping social values, and public and political opinion.
Broad social change, as well as more focused prevention and cessation initiatives, has drawn heavily on research findings from the behavioural sciences. Considerable effort (mainly, in Australian, in the NGO sector) has gone into documenting policy inputs and monitoring impact and outcome measures.
This chapter discusses why conceptualising tobacco-related harm from legal, economic and social policy perspectives should also help build support for tobacco control policy among academic and practising economists and lawyers, and in the business, welfare and government sectors.

Coronary angiography observations: evidence-based or ritualistic practice?

Objective: The purposes of this study were to describe the incidence and occurrence of femoral artery bleeding during the first 6 hours after coronary angiography and to determine whether there is a relationship between  current postangiogram observation protocols and the detection of  complications.

Design: This was a prospective descriptive study.

Setting: The study was conducted in 3 university hospitals in Melbourne, Australia.

Patients: Subjects included 55 patients representing the complication rate of 1075 patients, mean age 61 years (SD, 12), 69% male.

Results: About 5.1% of patients had 1 or more incidents of bleeding  requiring manual compression. In 4.2% of patients, bleeding occurred within 6 hours of angiography. Bleeding occurred a median of 2.02 hours (Q1 = 45 minutes, Q3 = 4.31 hours) after angiography. Patients without pressure bandaging bled a median of 1.32 hours (Q1 = 36.50 minutes, Q3 = 2.59 hours) after angiography. Patients with pressure bandaging bled a median of 4.75 hours (Q1 = 2.25 hours, Q3 = 7.28 hours) after angiography. In 40.6% of cases, bleeding was detected through the patient’s call for assistance, and in 59.4% of cases nurses noted bleeding while checking the puncture site. Postcatheter observations were recorded 23.70 (SD, 14.60) minutes before the bleeding incident. There were no significant changes in vital signs, systolic blood pressure (P > .05), diastolic blood pressure (P > .05), or pulse (P > .05) before or during a bleeding episode. All were within normal parameters. No neurovascular assessment anomalies were detected.

Conclusion: The use of pressure bandaging has a significant effect on the incidence and pattern of bleeding. Routine vital sign measurement has no relevance in detecting local complications after angiography. The most significant complication is bleeding that requires manual compression. Detection is through frequent puncture site observation and patient recognition and communication.

Is it only 'what works' that 'counts' in new knowledge economies? Evidence-based practice, educational research and teacher education in Australia

Recent texts on globalisation and education policy refer to the rapid flow of education policy texts producing or responding to common trends across nation states with the emergence of new knowledge economies. These educational policies are shaping what counts as research and the dynamics between research, policy, and practice in schools, creating new types of relationships between universities, the public, the professions, government, and industry. The trend to evidence-based policy and practice in Australian schools is used to identify key issues within wider debates about the ‘usefulness’ of educational research and the role of universities and university-based research in education in new knowledge economies.

Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update

This paper updates evidence reviewed in the first edition of Getting Australia Active on effective physical activity (PA) intervention strategies among children, adolescents and young adults. Intervention studies published between 1999 and September 2003 were identified using electronic databases and hand searching. A total of 28 discrete studies were identified (31 papers). Six of nine studies reported significant effects on child or youth PA in school settings. Those that incorporated whole-of-school approaches including curriculum, policy and environmental strategies appeared to be more effective than those that incorporated curriculum-only approaches. Five of 10 studies with children and two of five studies with adolescents reported increased PA or decreased sedentary behaviour in other settings. Interventions that included contact with families generally appeared to be most effective. One study with adolescents provided some evidence of the potential effectiveness of interventions based in primary care. Two of four papers reported modest short-term results among young adults, including increased PA stage of change or a higher likelihood of being adequately physically active, but none showed any evidence of sustained increases in PA. There is an urgent need for additional studies examining interventions aimed at young adults. Across the three life stages, future studies should include objective PA measures, longer-term follow-up, larger sample sizes, a specific focus on PA (rather than weight) and culturally-specific strategies that build evidence in Australian populations. Future studies should target high risk groups and a broad range of settings and strategies focusing on reducing sedentary behaviours as well as increasing PA.

Emergency nurses' opinions regarding paediatric fever: the effect of an evidence-based education program

Introduction: The beliefs and opinions of individual nurses are key factors in clinical decisions. Emergency nurses’ clinical decisions related to paediatric fever establish emergency department norms, provide role-modelling for both peers and parents, underpin clinical management of febrile children, and influence fever management advice given to parents. Aim: This study aimed to examine: (i) the opinions of emergency nurses regarding paediatric fever, and (ii) the effect of an evidence-based education program on the opinions of emergency nurses regarding paediatric fever. Method: This study used a prospective pre-test/post-test design. The primary outcome measure was emergency nurses’ opinions measured using the ‘General Opinions about Fever Management in Children’ survey. The intervention for the study was two tutorials. Pre-test data was collected in June 2005 and post-test data was collected during August 2005. Results: Thirty-one emergency nurses participated in the study. There were a number of positive changes in emergency nurses’ opinions regarding paediatric fever as a function of an evidence-based educational intervention. Major domains of change were relationship between temperature and illness severity/risk of harm, use and effects of antipyretic medication and febrile convulsions.  Conclusion: Emergency nurses are an important source of information for parents leaving the emergency department with a febrile child. Opinions can be a major influence in nurses’ clinical decisions and many fever  management strategies used by health care professionals are reflective of individual beliefs rather than the best available evidence. The results of this study showed a number of positive changes in emergency nurses’ opinions regarding paediatric fever as a function of an evidence-based educational intervention.

Evidence-based practice and the borders of data in the global information era

This article explores the range of boundaries to negotiate the demands of evidence-based practice. Increasing demands that social work be a profession committed to evidence-based practice have coincided with innovations in information technology, which potentially give social workers unprecedented access to a plethora of sources and types of evidence. Because these innovations can enable access to evidence beyond traditional boundaries, the question of how the author establish the borders of acceptability warrants consideration. Recommendations for a critical approach to selective evidence based for social work interventions are also provided.

Evidence based practice: are critical care nurses ready for it?

In the emergence of the evidence based practice movement, critical care nurses have struggled to identify scientific evidence on which to base their clinical practice. While the lack of critical care nursing research is a major concern, other important issues have significantly stalled the implementation of evidence even when it is available. A descriptive study of 274 critical care nurses was undertaken to examine nursing research activity in Victorian critical care units. The study aimed to identify critical care nurses' research skills, the barriers encountered in participation and implementation and the current availability of resources.

Results revealed that 42 per cent of the nurses who participated in the study believed that they were not prepared adequately to evaluate research, and less than a third believed they were sufficiently skilled to conduct valid scientific studies. An association was found between nurses' ability to confidently perform research activities and higher academic qualifications. The study found that there is a lack of organisational support and management commitment for the development of evidence based nursing.

In order to facilitate the implementation of evidence based practice, clinicians must be made aware of the available resources, be educated and mentored when carrying out and using clinical research, and be supported in professional initiatives that promote evidence based practice. It is argued that this will have positive implications for patient outcomes in the critical care environment.

Evidence-based paediatric practice and its relation to the Cochrane Collaboration

Focuses on the relation between evidence-based pediatric practice and the Cochrane Collaboration on health care. Formation of the collaboration; Aim of Cochrane Collaboration; Reaction of pediatricians to the collaboration; Ways by which the collaboration ensures its relevance to pediatrics and child health.