In a Department of Veterans Affairs hospital on the East Coast of the United States, behavioral outbursts result in 2 out of 10 veterans dismissed from a posttraumatic stress disorder (PTSD) unit prior to completing the 6-week program. The purpose of this evidence-based quality improvement project was to create a clinical practice guideline (CPG) based on social cognitive theory (SCT) to provide new strategies for managing veterans with PTSD and to improve the confidence of the nurses in managing outbursts. The Star Model guided the project development with the Delphi method to achieve participant consensus, the AGREE II to assess the CPG quality, and the Generalized Self-Efficacy (GSE) scale to measure the change in participant knowledge and confidence. The literature was searched, compiled, assessed, and shared with 10 participants, registered nurses on the PTSD unit. Through the Delphi process, the participants achieved consensus (8/10) for the CPG, with two neutral participants. The GSE was administered pre- and post-test and analyzed using a paired t test to measure the mean differences of the GSE scores. The data was normally distributed to different scores to gauge the impact of the CPG development process on improving nursing knowledge and confidence was normally distributed [t(9) = -4.188, p < 0.05, &, t(9) = -2.714, p =0.003]. The data indicated a significant increase in participant knowledge about role of SCT, and confidence toward implementing the CPG into clinical practice. This project contributes to positive social change as nurses identified a clinical practice problem, transferred evidence about strategies from the literature into their clinical practice through a CPG, and implemented the CPG with the knowledge and confidence to impact patient care.

Ineffective pain management in the post anesthesia care unit (PACU) increases patients' risk of adverse effects including decreased mobility, infection, chronic pain, depression, cardiopulmonary complications, increased length of stay, insomnia, fatigue, and overall decrease in quality of life. The PACU in a community hospital did not provide an evidence-based pain management guideline for nurses treating postoperative patients, resulting in nurses' concerns about providing pain management. The purpose of this project was to translate evidence on pain management into an evidence-based guideline for improved nursing practice in a PACU. Evidence was obtained from a detailed literature search using multiple databases and professional organizations' guidelines. Nursing practice guidelines were developed and evaluated by 3 expert panelists using the Agree II guidelines. The panelists selected included; Two anesthesiologists, one who is trained in pain management and is also a pharmacist. The third expert is a practicing nurse practitioner in an acute setting who is also a surgical first assist and the associate director of robotics. The panel endorsed the guidelines for advancement through the hospital's review committees. Implementation of the evidence-based pain management guideline in the PACU might provide nurses with tools to guide their interventions and improve patient outcomes. Social changes resulting from the use of evidence-based pain management guidelines include decreased time to opiate administration, decreased adverse effects, improved assessment of pain, and an increase in the number of patients who receive proper pain management.

Managing heart failure patients in the outpatient setting can pose a challenge for nurses and health care staff due to the need to educate patients on self-care skills and management of disease. Several factors, including health literacy and numeracy, need to be considered when developing an education program for heart failure patients to promote self-care management. The purpose of this project was to provide nursing staff with a clinical practice guideline (CPG) that incorporated health and numeracy literacy assessment into an individualized education program. The Johns Hopkins nursing evidence-based practice (EBP) model, the situation-specific theory of heart failure (HF) self-care, and Wagner's chronic care model guided the development and implementation of this project. The practice-focused question for this project asked whether evidence informs a CPG intended to assess health literacy and numeracy assessment and promote an enhanced individualized education intervention in an outpatient HF population. A literature review using 20 articles from 2006-2018 was completed. Five articles were selected to review levels of evidence, and three articles were chosen to support the development of the CPG. The CPG was reviewed, refined, and validated by an expert panel of HF nurses and physicians. The CPG might support a positive social change in the practice setting by improving the tools for nurses to assess health literacy in the HF patient population and provide individualized education to influence self-care interventions.

Purpose/Aims: The American Thoracic Society (ATS) published recommendations for alpha-1 antitrypsin deficiency (AATD) testing in 2003. This descriptive project evaluates the outcomes of ATS AATD guideline use in the setting of the pulmonary function testing (PFT) lab.The specific aims met by this descriptive project describe the prevalence of AATD cases and carriers in the sample, examine to what degree the established clinical guideline promoted accurate patient selection for the alpha-1 test in the sample, and aimed to determine whether alpha-1 antitrypsin blood levels are reduced in current smokers compared to former or never smokers.Background: Alpha-1 antitrypsin prevents lung tissue breakdown by attenuating excess elastase released from neutrophils during the inflammatory response. Smoking impairs alpha-1 antitrypsin protection at the site of lung inflammation promoting emphysema development. In the case of genetic mutation, protective alpha-1 antitrypsin levels are reduced, causing emphysema even in non-smokers. Significantly reduced protective levels of alpha-1 antitrypsin increase the odds for morbidity and early mortality from emphysema. The literature provides support for targeted testing in the population most affected.Sample/Methods: The sample population included adults 21 through 79 years completing pulmonary function testing over 18 months in a metropolitan pulmonary medicine practice and was retrospectively reviewed.Of the 521 in the sample, 190 were tested for AATD, and 24 were found to carry an abnormal genotype. However, using Table 11 from the ATS CPG failed to provide structured, consistent guidance in selecting patients for AATD testing. Still, the prevalence of the abnormal genotypes MS, MZ, SZ, and ZZ was increased in this pulmonary population compared to the published estimated prevalence for the general population.A structured decision-tree, developed from the original guideline for diagnostic testing, may provide superior guidance for AATD test patient selection in this setting. Increased case finding by targeted testing of patients in the setting of the pulmonary function lab can serve to integrate this clinical practice guideline in a consistent streamlined fashion.In this sample, no difference between AAT blood levels among ever, never, and current tobacco smokers was detected. A more powerful sample is needed.

Evidenced based nursing seeks to integrate new knowledge from current research into practice. The use of clinical practice guidelines is one method of accomplishing this. The purpose of this study was to assess the effect of differing clinical practice guideline representation formats on the quality of nursing care plans and on the experiences of nurses. To accomplish this, an experimental study taking place in a laboratory setting was executed. BC Cancer Agency nurses volunteered as the participants. The nurses were given case scenarios and asked to generate nursing care plans with the assistance of clinical practice guidelines. The clinical practice guidelines were presented in two formats: Portable Document Format (PDF) and Web Based Interactive (WBI). The quality of the care plans was rated using a validated evaluation tool. Participants were asked to ‘think-aloud’ during the care planning process and their experiences were recorded, transcribed, and analyzed through a cognitive task analysis. This study revealed advantages and disadvantages to both formats and provided insight into nurses' experiences. This study also showed no statistically significant difference in the quality of care plan documentation, regardless of clinical practice guideline format. This study highlights the importance of evaluating health informatics projects in healthcare settings to ensure positive outcomes in measures of user experience and measures of documentation quality. / Graduate / 0569 / 0758 / 0984 / csimad@gmail.com

Suicide is an issue that plagues adolescents in the United States. Suicide crosses socioeconomic, racial, and gender divides and is difficult to predict and prevent. Primary care providers (PCPs) are in a position to detect suicidality in adolescents; however, PCPs lack the knowledge and confidence necessary to accurately identify suicidal adolescents. The author conducted an extensive review of current literature (meta-analyses, systematic reviews, literature reviews, case reports, and existing clinical practice guidelines) on identification of adolescent suicidality in pediatric primary care settings. This paper provides a set of recommendations for primary care providers on how to properly identify adolescents with suicidal ideation and behavior.

Orientador: Paulo José Fortes Villas Boas / Resumo: Introdução: A população mundial de idosos vem crescendo mais rapidamente do que todos os outros grupos etários, demandando condições específicas para os seus cuidados, com recomendações bem estabelecidas. Recomendações de qualidade são essenciais para nortear o profissional de saúde, por isso, a United States Preventive Services Task Force (USPSTF) atua desde 1984 produzindo recomendações de qualidade científica para rastreio de doenças, com base no sistema GRADE (Grading of Recommendations Assessment, Development and Evaluation) de força de recomendação. No Brasil, o Ministério da Saúde tem publicado PCDTs (Protocolos Clínicos e Diretrizes Terapêuticas) sobre algumas condições clínicas, e as Sociedades Médicas produzem diretrizes sobre doenças específicas, mas ainda não há manuais organizados de recomendações clínicas. Recomendações com diretrizes clínicas de confiança devem ser a base para melhorar a qualidade e a segurança dos serviços de saúde. Objetivos: Revisão das recomendações da United States Preventive Services Task Force (USPSTF) destinadas ao rastreio das condições clínicas prevalentes da população idosa e comparação com recomendações desenvolvidas as Sociedades Científicas Brasileiras reconhecidas pela Associação Médica Brasileira, para produção de manual de rastreio clínico em idosos assintomáticos. Metodologia: Estudo descritivo, tendo como base principal as recomendações da USPSTF e consensos publicados pelas Sociedades Científicas Brasileiras e de órgãos gove... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: World elderly population is growing faster than any other age group, requiring specific care conditions. Recommendations of good quality are essential for health professionals in clinical practice, and the use of science-based references is the main goal. The United States Preventive Services Task Force (USPSTF) works since 1984 producing evidence-based recommendations for disease screening, based on GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system to evaluate the strength of evidence. In Brazil, the Ministry of Health has been publishing the Clinical Protocols and Therapeutic Guidelines (PCDT, in Portuguese) about some clinical conditions, and Medical Associations has been working on some guidelines about specific diseases, but the country still lacks organized clinical recommendations. Good quality, evidence-based recommendations must be the base to improve the quality and safety of health systems. Objectives: USPSTF clinical recommendations review of elderly prevalent diseases and comparison with Brazillian recommendations produced by national entities, with the purpose of elaborating a screening manual for asymptomatic elderly. Methodology: The research was a review of USPSTF recommendations and guidelines published by Brazilian Medical Associations and governmental entities. The USPSTF recommendations are classified according to the GRADE system, and the grades are: A. certainty of substantial benefit; B. certainty of benefi... (Complete abstract click electronic access below) / Mestre

Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?” Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.

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Background: Analytical frameworks (AF) are graphical representation of the key questions answered by a systematic review and can support the development of guideline recommendations. Our objectives are to a) conduct a systematic review to identify, describe and compare all AFs published as part of a systematic and guideline development process related to colorectal cancer (CRC); and b) to use this case study to develop guidance on how to conduct systematic reviews of AFs. Methods: We conducted a systematic review and searched Medline and Embase from 1996 until December 2020. We also manually searched guideline databases and websites. We identified all guidelines in CRC that utilized an AFs and all systematic reviews in primary prevention, screening, and diagnosis of CRC that used AFs. We assessed quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool. The systematic review was registered in PROSPERO, registration CRD42020172117. Results: We screened 34,505 records and identified 1166 guidelines on CRC and 3127 systematic reviews, of which 5 met our inclusion criteria identifying a total of 4 AFs in colorectal cancer. We describe our search strategy and methods for conducting systematic reviews for AFs. Conclusion: Few guidelines and systematic reviews are utilizing AFs in the development of recommendations. We developed methods for conducting a systematic review on AF / Thesis / Master of Science (MSc) / Analytical frameworks are graphical diagrams that represent key questions with flow of resining from population to outcome. We conducted a systematic review to identify all analytical frameworks in colorectal cancer and in the process we developed guidance on how to conduct a systematic review for analytical frameworks. We identified four analytical frameworks, one in primary prevention, and three in screening of colorectal cancer. We found only a few clinical practice guidelines that utilized analytical frameworks in the development of the recommendations. We developed methods for conducting a systematic review of analytical frameworks.