ContextDespite wide promulgation, clinical practice guidelines have had limited
effect on changing physician behavior. Little is known about the process and
factors involved in changing physician practices in response to guidelines.ObjectiveTo review barriers to physician adherence to clinical practice guidelines.Data SourcesWe searched the MEDLINE, Educational Resources Information Center (ERIC),
and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks
on health behavior or public health; and references supplied by experts to
find English-language article titles that describe barriers to guideline adherence.Study SelectionOf 5658 articles initially identified, we selected 76 published studies
describing at least 1 barrier to adherence to clinical practice guidelines,
practice parameters, clinical policies, or national consensus statements.
One investigator screened titles to identify candidate articles, then 2 investigators
independently reviewed the texts to exclude articles that did not match the
criteria. Differences were resolved by consensus with a third investigator.Data ExtractionTwo investigators organized barriers to adherence into a framework according
to their effect on physician knowledge, attitudes, or behavior. This organization
was validated by 3 additional investigators.Data SynthesisThe 76 articles included 120 different surveys investigating 293 potential
barriers to physician guideline adherence, including awareness (n = 46), familiarity
(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n
= 8), ability to overcome the inertia of previous practice (n = 14), and absence
of external barriers to perform recommendations (n = 34). The majority of
surveys (70 [58%] of 120) examined only 1 type of barrier.ConclusionsStudies on improving physician guideline adherence may not be generalizable,
since barriers in one setting may not be present in another. Our review offers
a differential diagnosis for why physicians do not follow practice guidelines,
as well as a rational approach toward improving guideline adherence and a
framework for future research.

https://www.ghdonline.org/uploads/Cabana_1999_JAMA_-_Why_dont_physicians_follow_clinical_practice_guidelines_-_a_framework_for_improvement.pdf

Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement

Objectives The relationship between physiologic status and mortality risk should be reevaluated as new treatment protocols, therapeutic interventions, and monitoring strategies are introduced, and as patient populations change. We developed and validated a third-generation pediatric physiology-based

PRISM III: An updated Pediatric Risk of Mortality score

ORTHOTOPIC liver transplantation is an effective therapy for end-stage liver disease and has proved to be a major advance in the treatment of liver disease in children.1 The foremost obstacle faced by transplantation units worldwide has been the relative paucity of infant and child donors. The principle of transplanting a portion of the liver from an adult into a child has been accepted in many centers.2 3 4 In March 1987, an orthotopic reduced-size liver transplantation was performed in Brisbane, Australia. This was our first experience with the technique, which involved the retention of the recipient's inferior vena cava, to which the . . .

Successful Liver Transplantation from a Living Donor to Her Son

Pediatric liver transplantation with reduced size donor organs (RLT) has evolved into a standard clinical procedure increasing the choices of recipients for their treatment. Nevertheless organ availability remains a major problem. The authors therefore have proposed to study the use of hepatic segments from living related donors (LRT) in a group of 20 children less than 2 years of age or weighing less than 15 kg, in whom standard indications for transplantation existed. Volunteer related donors were selected after medical and psychiatric evaluations, and the suitability of the donor's liver was established by functional and radiologic criteria. A two-stage informed consent process assured appropriate "volunteerism." Nineteen infants received LRT as first grafts and one as a second graft. Seventeen of the recipients are alive 3 to 18 months after LRT. Fifteen of 20 patients are currently at home with the original graft and normal liver function (bilirubin less than 1.5 mg/dl) after a median hospital stay of 27 days (range, 14-93 days). Four patients underwent retransplantation, in all cases due to arterial thrombosis. The overall graft survival for 20 primary LRTs is 75%, with follow-up between 3 and 18 months. A number of technical problems occurred during our initial trial, the most aggravating being vascular thrombosis. Refined approaches to vascular reconstruction should reduce the incidence of thrombosis and improve the rate of survival in future cases. The donor group for the initial 20 LRT procedures comprised 12 mothers, 7 fathers, and 1 grandmother. In addition one father and one uncle, who was an identical twin of the recipient's father, who did not qualify for anatomic reasons, were used in repeat LRT. All donors survived and are now in normal health between 3 and 18 months after LRT, having returned to all activities enjoyed before donation. The median hospital stay was 6 days (range, 5-14). Complications were minimal, and all were limited to the first three procedures, in which a full left hepatectomy was performed. After alteration of the procedure into a left lateral segmentectomy, no complications were encountered. The left lateral segmentectomy presents minimal surgical trauma to the liver and should remain the primary approach for obtaining a liver graft from a living donor. For children, transplantation of a left lateral segment from a live donor provides a new way of providing a transplant of appropriate size and with good function. The success of this program has led to the acceptance of LRT for general clinical application in the authors' institution.

Liver transplantation in children from living related donors. Surgical techniques and results.

OBJECTIVE: The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. SUMMARY BACKGROUND DATA: The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient. METHODS: From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-to-recipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient. RESULTS: Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the original graft at a median follow-up of 6.5 months (range, 5-10 months). CONCLUSIONS: When performed by a team with experience in hepatectomy and transplantation, LDLT, using an extended right lobe graft, can achieve superior results. The technique extends the success of LDLT from pediatric recipients to adult recipients and opens a new donor pool for adults to receive a timely graft of adequate function.

Adult-to-adult living donor liver transplantation using extended right lobe grafts.

Surgical reduction of donor livers to treat small children has been performed successfully in several centers. While this procedure improves the allocation of livers, it does not increase the organ supply. We have extended reduced-size orthotopic liver transplantation (OLT) to treat 18 patients with 9 livers, accounting for 26% of our transplants during a 10-month period and have evaluated the results. In 18 split liver OLTs, patient survival was 67% and graft survival was 50%. In comparison, for 34 patients treated with full-size OLT during the same period, patient survival was 84% (p = 0.298) and graft survival was 76% (p = 0.126). Biliary complications were significantly more frequent in split grafts, occurring in 27%, as compared to 4% in full-sized grafts (p = 0.017). Primary nonfunction (4% versus 5.5%) and arterial thrombosis (6% versus 9%) occurred with similar frequency in split and full-size OLT (p = not significant). These results demonstrated that split-liver OLT is feasible and could have a substantial impact in transplant practice. We believe that biliary complications can be prevented by technical improvements and that split-liver OLT will improve transplant therapy by making more livers available.

Transplantation of two Patients with one liver: Analysis of a preliminary experience with 'Split-liver' grafting

Since the establishment of a clinical program in liver transplantation in 1984, 162 liver transplants have been performed in 131 patients (78 adults, 53 children). The patient mortality rate while waiting for a suitable organ has been 8% for adults and only 4% for children (25-46% reported in the literature). The low pediatric mortality is a result of the use of reduced-size liver transplants. A total of 14 procedures have been performed in recipients whose clinical condition was deteriorating and for whom no full-size graft could be located. Of 14 children, 13 were less than 3 years of age. Patient survival is 50%, comparable to survival of high-risk recipients of full-size livers. Using reduced-size liver grafting in a transplant program can lower mortality for children awaiting a transplant by overcoming size disparity. Reduced-size liver grafting will allow more effective use of donor resources and provide a potential avenue of research for organ splitting and living related donation.

Liver transplantation, including the concept of reduced-size liver transplants in children

To calculate overall pediatric intensive care unit (PICU) efficiency rates, 1668 patients representing 6962 patient-days were studied in eight PICUs. The contributions to inefficiency by two patient groups—low-risk monitored patients and potential early-discharge patients—were quantified using measures of daily mortality risk and therapeutic assessments. Low-risk monitored patients never received a unique PICU therapy and had daily mortality risks less than 1%. Potential early-discharge patients were similar to the low-risk monitored patients except that their unnecessary PICU use came only on their last consecutive day(s) of PICU stay. Efficiency ratings ranged from 0.894 to 0.547 in the eight PICUs. Low-risk monitored patients constituted from 16% to 58% of the PICU patient populations and used from 5.4% to 34.5% of the total days of care. Potential early-discharge patients constituted from 12% to 29% of the populations and the potential early-discharge days of care ranged from 5.1% to 17.2% of the total days of care. These results indicate that large disparity exists in efficiency among PICUs. Efficiency rates of greater than 0.80 seem to be a reasonable goal. ( JAMA 1987;258:1481-1486)

https://jamanetwork.com/journals/jama/articlepdf/368196/jama_258_11_026.pdf

Efficiency of intensive care. A comparative analysis of eight pediatric intensive care units.

Objectivesa) To quantify the use of do-not-resuscitate orders in a tertiary care children's hospital; and b) to characterize the circumstances in which such orders are written.DesignRetrospective chart review.SettingUniversity teaching hospital.PatientsAll inpatients who died in an urban children's

Do-not-resuscitate orders in a children's hospital.

Transtracheal aspiration, percutaneous lung biopsy, and tracheal aspiration can be dangerous and/or unreliable methods for obtaining specimens of pulmonary secretions for culture. Using a blind technique, we evaluated the efficacy of a double-lumen catheter (DLC) with a polyethylene glycol plug in obtaining specimens of respiratory tract secretions for culture, and compared these results with simultaneously obtained cultures of tracheal aspirates. Twenty-seven intubated children already receiving antibiotic therapy were studied. Sixteen (59%) DLC specimens were sterile, as opposed to only 6 (22%) tracheal aspirates. Only 2 (8%) of the DLC specimens were contaminated. Two DLC specimens yielded significant bacterial growth (at least 10(5) colony-forming units/ml). Using DLC culture data, there was an 81% success rate in making decisions concerning antibiotic selection. We conclude that blind use of the DLC is a safe and reliable method of obtaining pulmonary secretion specimens for culture.

Aaron R. Zucker

Papers

Transplantation of two Patients with one liver: Analysis of a preliminary experience with 'Split-liver' grafting

Liver transplantation, including the concept of reduced-size liver transplants in children

Efficiency of intensive care. A comparative analysis of eight pediatric intensive care units.

Do-not-resuscitate orders in a children's hospital.

Blind use of the double-lumen plugged catheter for diagnosis of respiratory tract infections in critically ill children.