Acute low back pain is a commonly occurring symptom that can impact considerably upon a person's life. It is poorly defined, difficult to classify and challenging to measure. However, due to the high prevalence rates of the symptom, cited in the epidemiological literature, and the costs incurred by individuals, health services and society in general, it is vital that clients are encouraged to take more responsibility for their health. This thesis is concerned with perceptions of control in people with acute low back pain. It is about how they respond to this symptom and the way it impacts upon their lives. The underpinning literature is drawn from both medical and social science research, as the work crosses faculty boundaries. Problems are addressed from a physiotherapeutic and social science perspective, as links are formed between the different disciplines. From this literature, a significant theoretical development was the creation of a framework, which enabled the systematic review of existing outcome measures. A number of instruments, relevant to clients with acute low back pain, were reviewed using this framework, for the dimensions of control, function, pain and anxiety. The findings were used to inform the selection of outcome measures in this research. Four studies were then undertaken, all linked to studying clients with acute low back pain. The first study was a survey of general practitioners in Southampton and the New Forest, which identified their strategies for managing clients with acute low back pain. The second study focused on clients' experiences and was a randomized controlled trial, which tested the effectiveness of an information leaflet, designed to encourage clients to take more responsibility for their own health. The third study primarily focused on clients' perceptions of control over time, addressing the question of how these perceptions change during a one-year period. Finally, since recruitment of clients by their doctors was problematic throughout this research, a follow-up survey was undertaken with these health professionals to establish the reasons for this. The results of these studies are used to discuss the importance of clients' perceptions of control and the implications for clinical practice.

Introduction: The number of older adults (≥ 65 years) is increasing in Sweden. At the same time, the elderly care system is being restructured with an increased care burden in nursing homes (NHs). Several studies report a high prevalence of malnutrition among older adults. In recent years public awareness about malnutrition has increased and collective initiatives have been undertaken. However, we lack knowledge regarding how to implement these initiatives to achieve real improvements in practice. Aims: The overall aims of the thesis are to update our knowledge of the nutritional situation in municipal elderly care and to evaluate different implementation strategies (external facilitation and educational outreach visits) for implementing nutritional guidelines in the NH setting. Methods: Residents and staff of altogether eight NH units participated in the studies. The two implementation strategies were external facilitation (EF) and educational outreach visits (EOV). The EF strategy was a one-year, multifaceted intervention that included support, guidance, practice audits and feedback in four NH units. The EOV strategy comprised one three-hour lecture about the nutritional guidelines in four other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Results: In paper I, the prevalence of malnutrition in the NH setting remained high, i.e., 30% were malnourished and 63% at risk of malnutrition, and malnutrition was associated with deterioration in function and cognition and one-year mortality. However, possible improvements in nutritional status among NH residents over time (from 1996 to 2010) were observed. In paper II, the EF strategy improved mealtime ambience compared to the EOV strategy with respect to arranging the table, offering a choice of beverage and more to drink, serving the meal, increasing social interactions between staff and residents, decreasing social interactions among staff and reducing noise from the kitchen. In paper III, the EF strategy may have been related to a delay in cognitive deterioration in a sub-sample of communicative NH residents. In paper IV, the EF strategy improved, on average, the ability and willingness of the staff to implement the guidelines, i.e., the staff experienced a clearer assignment of responsibilities regarding nutritional procedures and that they had more time, tools and support from leadership. Moreover, the staff felt that they experienced less resistance from work colleagues, that their knowledge and experience were valued, that the guidelines worked in practice and that the implementation of guidelines was not labourious.  Conclusions: Malnutrition is prevalent in Swedish nursing homes. Implementation of nutritional guidelines by an external facilitator, as compared to traditional methods, may be more effective on mealtime ambience, provide better preconditions for change among the staff, and may have positive effects on cognition among residents.

N. Gonorrhoeae is a major public health concern due to its capacity to develop antibiotic resistance and its potential complications including pelvic inflammatory disease, epididymitis, infertility, and disseminated infection. In order to keep up with resistance trends, the treatment recommendations for gonorrhea have changed frequently. In other areas of medicine, guideline adherence has been shown to be limited, even without frequent guideline changes. In the case of gonorrhea, inappropriate treatment can have serious individual and public health implications, making the quality of and compliance with clinical guidelines critical. This thesis is a three-part mixed methods research project assessing the development and uptake of gonorrhea treatment guidelines. We conducted a systematic review of current gonorrhea treatment guidelines and used the AGREE II tool to assess the quality of guideline development (Chapter 2). We observed that guideline quality varied greatly with many guidelines having weaknesses in their use of existing evidence to develop recommendations, their reporting of potential conflicts of interest and how they were addressed, and their consideration of barriers to the implementation of their recommendations. We then assessed physician adherence to first-line treatment recommendations in Ontario by conducting a segmented time series analysis of Ontario gonorrhea treatment data from iPHIS, the province’s reportable disease database (Chapter 3). Following the introduction of new guidelines that recommended substantial changes from current practice, we found very dramatic drops in guidelines adherence that then improved slowly over time. We then explored the use of process mapping as a tool to look at the local management of cases in the City of Ottawa by following them across the various possible treatment pathways (Chapter 4). Here, we noted differences in practice between the management of cases at Ottawa Public Health’s Sexual Health Clinic and the management of cases elsewhere in the community.

Sammanfattning Bakgrunden beskriver hur barnmorskans arbete ska byggas på vetenskap och beprövad erfarenhet enligt gällande författningar, förordningar, föreskrifter och andra riktlinjer. Det åligger därför barnmorskan att kunna söka, analysera och kritiskt granska relevant kunskap för att kunna delta i utvecklingsarbete eller dess utvärdering. Det finns ett värde i att reflektera över befintliga rutiner och vid behov medverka till en förändring samt implementera ny kunskap. Kliniska riktlinjer har tagits fram för att underlätta det kliniska arbetet och det är därför viktigt att riktlinjerna innehåller evidensbaserad forskning. Syftet med studien var att granska och värdera kvaliteten av lokala behandlingsriktlinjer gällande mödrahälsovårdens basprogram. En kvantitativ metod valdes för att besvara studiens syfte där granskningsinstrumentet AGREE II användes, vilket är framtaget för att kunna bedöma kvalitén angående utvecklingsprocessen av kliniska riktlinjer inom hälso- och sjukvården.  Resultatet från aktuell studie visade att avsnittet mål och syfte innehöll stora variationer gällande hur tydligt formulerat syfte de olika kliniska riktlinjerna hade. Inom berörda intressenters delaktighet framkom bristfällig dokumentation angående vilka yrkeskategorier som varit delaktiga i processen även patienters åsikter saknades. Inom stringens i framställningen erhöll alla kliniska riktlinjer låga poäng, beskrivning av litteratursökningen samt val av metod saknades. Samtliga kliniska riktlinjer i avsnittet tydlighet och framställning saknade eller hade otydliga behandlingsalternativ. Däremot kunde huvudrekommendationerna urskiljas med lätthet i sju av 18 kliniska riktlinjer. I avsnittet tillämpbarhet saknade samtliga kliniska riktlinjer resonemang kring hälsoekonomiska frågor eller angående behovet av eventuella organisatoriska förändringar. Redaktionell självständighet lyftes inte fram i någon av de kliniska riktlinjerna. Ingen klinisk riktlinje fick genomgående bra poäng i helhetsbedömningen enligt AGREE II, vilket gör det svårt att rekommendera någon av de kliniska riktlinjerna utifrån dess nuvarande presentation. Med detta resultat i åtanke anser författarna att de kliniska riktlinjer som granskades i aktuell studie inte har någon påvisbar evidensbaserad grund enligt AGREE II-instrumentet och kan således inte rekommenderas att använda som stöd i det kliniska arbetet. / Abstract The work of the midwife should be based on science and knowledge according to statutes, ordinances, regulations and available guidelines. In order to participate in development work and evaluation of it, it is important for the midwife to search, analyze and critically examine the relevant knowledge. To help the nursing staff in their clinical work and to provide quality proof care to the patients, clinical guidelines have been developed. It is therefore important that the content of the clinical guidelines is based on evidence-based research and easy to understand. The aim of the study was to review and evaluate the quality of local clinical guidelines regarding the basic maternity health care program. A quantitative method was used and the clinical guidelines were reviewed using the instrument AGREE II. The findings revealed that the quality of the clinical guidelines evaluated in this study varied. The result from current study showed that the section scope and aim contained big variations regarding how clearly the purpose was formulated in the different clinical guidelines. Within the section stakeholders involvement inadequate documentations revealed, containing the occupational category the professionals who was involved in the process had, also the patients’ options were missing. Within the rigour of development all clinical guidelines gained low credits, the description of the literature search as well as the choice of method were missing. All the clinical guidelines in the section of clarity and presentation were missing or had unclear assessment alternatives. However the main recommendation could easily be distinguished in seven of the eighteen clinical guidelines. In the section of applicability all of the clinical guidelines were missing argument regarding health economics or the need of possible organizationally changes.  Editorial independence was not highlighted in any of the clinical guidelines. No clinical guideline had consistently good points according to AGREE II in the overall assessment. Therefore it is hard to recommend any of the clinical guidelines as they currently stands. With these results in mind authors of this study believes that the clinical guidelines that were viewed in this study did not, according to AGREE II, have any evidence-based ground demonstrable and can therefore not be recommended to nursing staff to be used as support in their clinical work.

No description available.

Guideline development processes influence the quality of clinical guidelines. The aim of this study was to use the AGREE II instrument to evaluate the variability of the quality of selected guidelines, to determine a baseline for the quality of current guidelines and determine whether guidelines demonstrated good standard practice during their development. The AGREE II instrument was used to assess a selection of guidelines published between January 2012 and June 2013. Eleven guidelines were selected for review. Overall, guidelines scored highest in domain 1 (Scope and purpose) and 4 (Clarity of presentation); and lowest in domain 3 (Rigour of development) and 6 (Editorial independence) with the overall assessment score of three out of seven. The study demonstrated that the quality of guidelines was variable and that there are deficiencies in the guideline development process. The results from this study provide a baseline to measure the quality of future guidelines. / Dissertation (MSc)--University of Pretoria, 2014. / tm2015 / School of Health Systems and Public Health (SHSPH) / MSc / Unrestricted

Svår sepsis och septisk chock är sjukdomstillstånd som kan orsaka ett stort lidande för patienten genom att de är förknippade med hög mortalitet och morbiditet. Tidig identifiering och adekvat antibiotikabehandling är avgörande för prognosen. Detta ställer höga krav på ambulanssjukvårdens kvalitet. Ambulanssjukvården har behandlingsriktlinjer som ska utgöra beslutsunderlag och kvalitetssäkring för den givna vården. De potentiella vinsterna med en behandlingsriktlinje blir dock aldrig bättre än kvaliteten på behandlingsriktlinjen i sig. Studiens syfte var att granska och värdera kvaliteten på den svenska ambulanssjukvårdens behandlingsriktlinjer rörande patienter med misstänkt svår sepsis och septisk chock. En kvantitativ metod nyttjades och en totalundersökning av behandlingsriktlinjer i svensk ambulanssjukvård genomfördes, där respektive ambulansorganisation i Sveriges tjugoen landsting kontaktades. Svarsfrekvensen var 76%. Utav dessa kunde nio inkluderades i studien (N = 9). De erhållna prehospitala behandlingsriktlinjerna granskades därefter med hjälp av AGREE II-instrumentet. Resultatet belyser dels att flera organisationer helt saknar behandlingsriktlinjer rörande patienter med misstänkt svår sepsis och septisk chock (33% av alla tjugoen kontaktade landsting. 44% av de sexton som svarade) samt att de övriga behandlingsriktlinjerna har metodologiska brister i rapporteringen kring hur behandlingsriktlinjerna togs fram. Detta utgör ett hinder för att behandlingsriktlinjerna ska kunna utgöra den kvalitetssäkring de är avsedda att vara. Bristerna kan härledas till ambulanssjukvårdens organisation och skulle eventuellt kunna avhjälpas genom centralt utvecklade nationella behandlingsriktlinjer finansierade av vårdgivaren. / Program: Specialistsjuksköterskeutbildning med inriktning mot ambulanssjukvård

Under år 2011 levde ca 5800 personer i Sverige med diagnosen hiv (humant immunbristvirus) och 18 nya fall upptäcktes via MHV:s screening av gravida kvinnor. Risken att ett barn smittas under graviditet och förlossning är 15-25 % om kvinnan inte behandlas med antiretrovirala läkemedel. Riskerna ökar med ytterligare 10-15 % om kvinnan sedan väljer att amma sitt barn. Barn till kvinnor som behandlas med antiretrovirala läkemedel och har icke mätbara virusnivåer i blodet löper en risk på 0,4-1 % att smittas. RAV (referensgruppen för antivirala medel) uppdaterade 2010 sina behandlingsrekommendationer för hiv-1 positiva kvinnor under graviditet och förlossning. Detta till följd av att WHO ändrade sina riktlinjer samma år. En stor skillnad i rekommendationerna är att kvinnan får möjlighet till en vaginal förlossning om virusmängden och den obstetriska anamnesen tillåter. Syftet med studien var att granska PM för handhavandet av den hiv-1 positiva kvinnan och hennes barn under förlossning och puerperium på förlossningskliniker i Sverige. En kartläggningsstudie valdes med beskrivande och jämförande design. Metoden var att samla in samtliga förlossningsklinikers PM och/eller strategi för omhändertagande av patientgruppen. De insamlade PM:en granskades enligt RAV:s behandlingsrekommendationer och enligt AGREE som är ett validitetssäkrat instrument för granskning av kliniska riktlinjer. Resultatet visar på stor variation i både uppbyggnad av PM och följsamhet till behandlingsrekommendationer. Förlossningsklinikernas behandlingsstrategier skiljer sig också åt beroende på antal förlossningar/år och huruvida de tog emot eller skickade vidare patientgruppen. Vissa förlossningskliniker saknade helt PM och några av dessa tog ändå emot patientgruppen. Generellt sett var PM:ens utformning undermålig gällande uppbyggnad och uppdatering, samt att flera förlossningskliniker ej hade anammat de nya behandlingsrekommendationerna från RAV. / In 2011, approximately 5800 people in Sweden were living with an hiv (human immunodeficiency virus) diagnosis and 18 new cases were detected during antenatal screenings of pregnant women. The risk of a child being infected during pregnancy and delivery is 15-25 % if the woman hasn’t been treated with antiretroviral drugs. The risk will increase a further 10-15 % if the woman choses to breastfeed the child. The children of women that are treated with antiretroviral drugs and has non-measureable levels of virus in the blood runs a risk of 0.4-1 % of being infected. In consequence of WHO changing their guidelines in 2010, RAV (a reference group for antiviral treatment) updated their treatment recommendations for hiv-1 positive women during pregnancy and delivery. A major difference in the recommendation is that the woman is given an option of vaginal delivery, if allowed by the viral levels and obstetrical history.The purpose of this study was to review PM for the handling of the hiv-1 positive woman and her child during delivery and puerperium on maternity clinics in Sweden. A survey study was chosen with descriptive and comparative design. The method was to gather PM and/or strategy for care of the patient group from all clinics. The gathered PMs were reviewed according to RAV’s treatment recommendations and according to AGREE, an instrument for examination of clinical guidelines. The result displayed a great variation in both PM structure and adherence to the treatment recommendations. The care strategy of a maternity clinic was dependent of deliveries per year and also whether the patient group was admitted or referred. Some maternity clinics lacked PMs entirely and some of these would nevertheless admit the patient group. In general, the form of the PMs were substandard regarding structure and maintenance and several of the maternity clinics had not embraced the new treatment recommendations from RAV.

Clinical guidelines are developed to assist healthcare practitioners to make decisions on a patient&#039 / s medical problems and as such they communicate with external applications to retrieve patient data, to initiate medical actions through clinical workflows and to transmit information to alert/reminder systems. The interoperability problems in the healthcare IT domain for interacting with heterogeneous clinical workflow systems and Electronic Healthcare Record (EHR) Systems prevent wider deployment of clinical guidelines because each deployment requires a tedious custom adaptation phase. In this thesis, we provide machine processable mechanisms that express the semantics of clinical guideline interfaces so that automated processes can be used to access the clinical resources for guideline deployment and execution. For this purpose, we propose a semantically enriched clinical guideline representation formalism by extending one of the computer interpretable guideline representation languages, GuideLine Interchange Format (GLIF). To be able to deploy the semantically extended guidelines to healthcare settings semi-automatically, the underlying application&#039 / s semantics must also be available. We describe how this can be achieved based on two prominent implementation technologies in use in the eHealth domain: Integrating Healthcare Enterprise (IHE) Cross Enterprise Document Sharing Integration Profile (XDS) for discovering and exchanging EHRs and Web service technology for interacting with the clinical workflows and wireless medical sensor devices. Since the deployment and execution architecture should be dynamic, and address the heterogeneity of underlying clinical environment, the deployment and execution is coordinated by a multi-agent system. The system described in this thesis is realized within the scope of the SAPHIRE Project.

Semantic web based decision support systems represent domain knowledge using ontologies that capture the domain concepts, their relationships and instances. Typically, decision support systems use a single knowledge model—i.e. a single ontology—which at times restricts the knowledge coverage to only select aspects of the domain knowledge. The integration of multiple knowledge models—i.e. multiple ontologies—provides a holistic knowledge model that encompasses multiple perspectives, orientations and instances. The challenge is the execution-time merging of multiple ontologies whilst maintaining knowledge consistency and procedural validity. Knowledge morphing aims at the intelligent merging of multiple computerized knowledge artifacts—represented as distinct ontological models—in order to create a holistic and networked knowledge model. In our research, we have investigated and developed a knowledge morphing framework—termed as OntoMorph—that supports ontology merging through: (1) Ontology Reconciliation whereby we harmonize multiple ontologies in terms of their vocabularies, knowledge coverage, and description granularities; (2) Ontology Merging where multiple reconciled ontologies are merged into a single merged ontology. To achieve ontology merging, we have formalized a set of semantically-defined merging criteria that determine ontology merge points, and describe the associated process-specific and knowledge consistency constraints that need to be satisfied to ensure consistent ontology merging; and (3) Ontology Execution whereby we have developed logic-based execution engines for both execution-time ontology merging and the execution of the merged ontology to infer knowledge-based recommendations. We have utilized OWL reasoning services, for efficient and decidable reasoning, to execute an OWL ontology. We have applied the OntoMorph framework for clinical decision support, more specifically to achieve the dynamic merging of multiple clinical practice guidelines in order to handle comorbid situations where a patient may have multiple diseases and hence multiple clinical guidelines are to be simultaneously operationalized. We have demonstrated the execution time merging of ontologically-modelled clinical guidelines, such that the decision support recommendations are derived from multiple, yet merged, clinical guidelines such that the inferred recommendations are clinically consistent. The thesis contributes new methods for ontology reconciliation, merging and execution, and presents a solution for execution-time merging of multiple clinical guidelines.