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Physician compliance not a given with evidence-based protocol changes


By Sabriya Rice
Posted: January 29, 2014 - 1:15 pm ET
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Lack of physician compliance with evidence-based protocols may progress in efforts to improve outcomes and make hospitals safer, but a study of wider-scale standardization at the Mayo Clinic is showing promise as a means of getting doctors on board.

A nationwide survey of 1,534 intensive-care units in 975 U.S. hospitals enrolled in the National Healthcare Safety Network found, for example, that there was varied compliance with protocols implemented to prevent healthcare-associated infections. Adherence to prevention policies ranged from 37% to 71% for central line-associated bloodstream infections, 45% to 55% for ventilator-associated pneumonia and only 6% to 27% for catheter-associated urinary tract infections, according to a study released Tuesday by Columbia University and the Centers for Disease Control and Prevention.

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“Establishing policies does not ensure clinician adherence at the bedside,” said the study authors, who wrote that they were surprised by the results. The ability of infection prevention and control programs to effectively implement evidence-based procedures is needed to drive down the rates, they said.

“Physicians are like any of us—change for change sake is not enough to motivate different behaviors,” said Melissa McCain, clinical transformation practice leader at the Chartis Group, a healthcare management consulting firm. The key is to employ “a well thought out and collaborative approach,” she said, noting that evidenced-based protocols may vary considerably from one organization to the next, and even among different departments within an organization.

Wide-scale standardization of these processes may be one way to gain this compliance, and a new study from the Mayo Clinic on stroke patients offers some insight into a collaborative approach that worked.

A report on the initiative released Monday found use of one standardized protocol across 20 medical centers helped significantly reduce death rates among victims of stroke. “By treating every patient in the exact same way and preparing for each issue we may encounter, we were able to reduce patient mortality by about 50%,” said study author Dr. Douglas Chyatte of the Mayo Clinic Health System.

The protocol was approved by each hospital's institutional review board, as well as a data coordinating center and performance and safety monitoring board. Adherence was required for a medical center to participate. The authors say the study results prove the potential to alter patient outcomes through medical management.

During the past decade, evidence-based protocols have been suggested for managing everything from blood pressure to foot ulcers, but lack of compliance means important safety precautions may slip through the cracks and unnecessary procedures may be performed.

“Care that is important is often not delivered. Care that is delivered is often not important,” wrote an Institute of Medicine roundtable on evidence-based medicine. In 2006, the group announced a goal of having 90% of clinical decisions be supported by accurate, timely and up-to-date clinical information, and reflect the best available evidence by the year 2020.

Management experts say healthcare organizations implementing their own best practices should engage physicians throughout the process to encourage cooperation.

“Asking someone to change course and simply adopt something given to them without rigorous review and challenge can at times lead to perceived resistance to change,” said McCain at Chartis, which helps organizations develop protocols. “Even without strict enforcement, there are ways for the organization to support and encourage adherence, such as transparency of performance data and retraining of the broader care team on elements that complement and support the protocol.”

Follow Sabriya Rice on Twitter: @MHsrice


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