Pressure sore prevention in the critically ill: what you don't know, what you should know and why it's important.

The critically ill are particularly vulnerable to pressure sore development. These expensive and often painful complications have been largely ignored for many years and the entire problem has been managed by nursing staff. Current methods for identifying patients at risk are inadequate and subjective. Scoring systems have been known to over-predict those at risk and this maybe because they frequently originate from elderly care settings. Additionally, their relevance to the critically ill has not yet been established. The use of pressure-relieving devices has become commonplace; however, there is a paucity of data from controlled clinical studies. No uniform approach in measuring the effectiveness of these devices exists. What is certain, though, is that a voluminous amount of work needs to be conducted in order to verify their continued use. It is increasingly apparent that the complex nature of pressure sore development means that it is unrealistic to expect a single discipline to manage the problem effectively. A multidisciplinary team approach is the most appropriate way to improve management in this vital area.     

Complications and side effects associated with epidural bupivacaine/morphine analgesia

Postoperative analgesia is a responsibility that physicians should fulfil in every patient. It is not only an act of kindness, but also an improved clinical outcome may be derived from this service when epidural techniques are used. However, complications and side effects may occur with postoperative epidural analgesia. Thus, there have been concerns among some clinicians regarding the use of local anaesthetics and opioids for epidural analgesia in the surgical wards where monitoring of patients is not as strict as it is in critical care or step down units. A review of the literature reflects a low incidence of side effects and complications in the surgical wards where the nursing staff have been trained in the early recognition of potential complications and the treatment of side effects. Many issues remain to be addressed via further research efforts. However, we believe that the current knowledge on potential complications and side effects of postoperative epidural analgesia and their treatment, allow for the safe epidural delivery of combinations of local anaesthetics and opioids in a wide range of postoperative patients. We also present the protocols that we currently use in our Acute Pain Treatment Service for the management of these complications and side effects.     

Nursing students can help support evidence-based practice on clinical nursing units

AIMS: A research study was designed to explore whether research utilization projects underwent by student nurses could have an impact on nursing practice on clinical nursing units. BACKGROUND: The use of evidence-based practice is becoming essential for nursing managers and nursing staff, but there are many barriers to implementing research findings in practice. Student nurses can be used to assist when staff nurses do not have time during the work day. METHODS: Baccalaureate nursing students completed a research utilization project during their final comprehensive clinical experience. Telephonic interviews were conducted with the students' preceptors 5 months after the students' clinical experience, to obtain their perceptions of the impact of the student project on the nurses' knowledge and practice. RESULTS: The staff nurse preceptors reported the projects were well received with the primary impact of the projects being to educate the nursing staff and patients and thus improve the level of nursing practice on the clinical units. CONCLUSIONS: Student research utilization projects are one way to save time for staff nurses and increase their awareness of current research findings.     

No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation

BackgroundInitial recommendations discouraged high flow nasal cannula (HFNC) in COVID-19 patients, driven by concern for healthcare worker (HCW) exposure. Noting high morbidity and mortality from early invasive mechanical ventilation, we implemented a COVID-19 respiratory protocol employing HFNC in severe COVID-19 and HCW exposed to COVID-19 patients on HFNC wore N95/KN95 masks. Utilization of HFNC increased significantly but questions remained regarding HCW infection rate.MethodsWe performed a retrospective evaluation of employee infections in our healthcare system using the Employee Health Services database and unit records of employees tested between March 15, 2020 and May 23, 2020. We assessed the incidence of infections before and after the implementation of the protocol, stratifying by clinical or non-clinical role as well as inpatient COVID-19 unit.ResultsDuring the study period, 13.9% (228/1635) of employees tested for COVID-19 were positive. Forty-six percent of infections were in non-clinical staff. After implementation of the respiratory protocol, the proportion of positive tests in clinical staff (41.5%) was not higher than that in non-clinical staff (43.8%). Of the clinicians working in the high-risk COVID-19 unit, there was no increase in infections after protocol implementation compared with clinicians working in COVID-19 units that did not use HFNC.ConclusionWe found no evidence of increased COVID-19 infections in HCW after the implementation of a respiratory protocol that increased use of HFNC in patients with COVID-19; however, these results are hypothesis generating.     

Autotransfusion--a technique for the trauma patient.

The use of autotransfusion--the retrieval and reinfusion of shed blood--has been demonstrated to be a beneficial therapeutic modality for the trauma patient. The use of autotransfusion is indicated for major blood losses of the patient who experiences blunt or penetrating trauma and has an external or a cavitational bleeding source. Advantages and disadvantages are numerous. It does appear that because of the low incidence of complications and the many advantages, autotransfusion will become a widespread resuscitative technique for use with the trauma patient. The procedure also has clinical application for those other than trauma patients. The nursing implications suggested by this new modality are many, including legal considerations, safety factors, protocol adoption, and new nursing roles. Perhaps the most positive benefit to nursing is the opportunity for clinical nursing staff (ER and OR) to become involved in nursing research that they can apply directly to their clinical setting.     

P25Overnight Transfusions Expose Patients to Unnecessary Risk and Seldom Facilitate Next Day Discharge

Aims and Objectives The Serious Hazards of Transfusion (SHOT) Committee has highlighted the increased risk of overnight transfusion in its annual reports. The risk arises from the paucity of staff (compared to daytime) to monitor patients and manage complications. The darkness on the ward can also obscure early clinical detection of clinical problems. Additionally, patients receiving the transfusion are prevented from sleeping and others in their bay are disturbed throughout the night. The commonest reason offered for overnight transfusion was to enable patient discharge the following day. After seeking approval from the Hospital Transfusion Committee, we performed two ‘snapshot’ studies to investigate the proportion of all transfusions given overnight. Having established that this was a significant number, fifty sequential overnight transfusions were further examined to see whether they were clinically appropriate and whether the recipients were actually discharged the following day. Evidence base/standards. ‘Overnight’ was defined as between 8 pm and 6 am as these are the times between which nursing and medical staffing levels are at their lowest. Transfusions were judged to be appropriate if they were for patients who: ? were actively bleeding ? admitted symptomatically anaemic during the night ? peri‐operative Methodology Each morning the Transfusion Practitioner examined the laboratory copies of the transfusion compatibility reports to identify the overnight transfusions. The medical notes for the transfused patients were then consulted for documented evidence as to the appropriateness of each episode according to the criteria above. Results From the two snapshot studies (each of a month), it transpired that, 43% of units of red cells were given to 40% of the patients and 26% of the units to 42% of the patients. This established that the project would be worthwhile. Of the 50 transfusion episodes, there was documentation in the notes of 30 patients (60%) of the need for transfusion. Seven patients (14%) were noted to be symptomatically anaemic and 3 (6%) bleeding. In total 20% of the overnight transfusions were appropriate by our criteria. Next day discharge occurred in five of the 50 patients. Further work was done to investigate possible delays in commencing the transfusions. Recommendations and actions The main action taken was to educate staff that inappropriate overnight transfusions compromised their patients’ care and rarely allowed earlier discharge. This was done through re‐enforcement at induction lectures, the Blood Transfusion Policy and a sign on the blood fridge.     

Quality benefits of an intensive care clinical information system

OBJECTIVE: This study was performed to quantify the quality benefits and staff perceptions of a computerized clinical information system implementation in an intensive care unit. Although clinical information systems have been available and implemented in many intensive care units for more than a decade, there is little objective evidence of their impact on the quality of care and staff perceptions. DESIGN: A longitudinal observational study before and after clinical information system implementation. SETTING: A 12-bed adult general intensive care unit in a large Australian tertiary referral teaching hospital. INTERVENTION: Implementation of a fully featured clinical information system to replace paper-based charts of patient observations, clinical records, results reporting, and drug prescribing. MEASUREMENTS AND MAIN RESULTS: The frequency of clinical adverse events over a 4-yr period using an established reporting system was examined. Pre- and postimplementation staff questionnaires were distributed and analyzed. There were significant reductions in the rates of medication, intravenous therapy, and ventilator incidents. There was a trend toward a reduction in pressure sores. The survey, utilizing a validated questionnaire, demonstrated a positive perception of the clinical information system by nursing staff, with less time spent in documentation and more time in patient care. Nursing staff recruitment and retention improved after clinical information system implementation. CONCLUSIONS: Implementation of a fully featured clinical information system was associated with significant improvements in key quality indicators, positive nursing staff perceptions, and some positive resource implications.     

Structures and practices enabling staff nurses to control their practice

This mixed-methods study uses interviews, participant observations, and the CWEQII empowerment tool to identify structures and attributes of structures that promote control over nursing practice (CNP). Nearly 3,000 staff nurses completed the Essentials of Magnetism (EOM), an instrument that measures CNP, one of the eight staff nurse-identified essential attributes of a productive work environment. Strategic sampling is used to identify 101 high CNP-scoring clinical units in 8 high-EOM scoring magnet hospitals. In addition to 446 staff nurses, managers, and physicians on these high-scoring units, chief nursing officers, chief operating officers, and representatives from other professional departments are interviewed; participant observations are made of all unit/departmental/hospital council and interdisciplinary meetings held during a 4 to 6 day site visit. Structures and components of viable shared governance structures that enabled CNP are identified through constant comparative analysis of interviews and observations, and through analysis of quantitative measures.     

Emotional dysfunction in a geriatric population: staff observations and patients' reports.

This study was designed to determine the following about a geriatric rehabilitation population: (1) the relationship between patients' self-reports of depression and anxiety and staff observations of compromised participation in treatment secondary to emotional dysfunction; (2) the relationship of observations among different disciplines; and (3) changes that may occur to staff observations during the patient's hospitalization. The Geriatric Depression Scale, the depression and anxiety subtests of the Brief Symptom Inventory, and the Modified Mini-Mental State Exam were administered to geriatric patients on admission to and discharge from two DRG-exempt acute rehabilitation units. In addition, day nurses, evening nurses, occupational therapists, and physical therapists rated the same geriatric patients on how frequently their emotional functioning interfered with rehabilitation. Significant correlations were obtained between staff observations and patients' reports of emotional dysfunction, with occupational therapists' ratings generally the most highly correlated with patients' reports. At admission, day and evening nurses reported significantly greater patient emotional dysfunction than did occupational therapists, who reported significantly greater emotional dysfunction than did physical therapists. These differences, however, were not evident by time of discharge. Thus, staff members can provide reliable information to mental health professionals in determining the effect of emotional functioning on rehabilitation participation. However, level of compromised participation secondary to emotional dysfunction reported by staff appears to be contingent on which rehabilitation discipline is asked and when during the patient's hospitalization the inquiry is made. Also, patients who generally participated less in treatment tended to be older, depressed women with less education and greater cognitive impairment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Analysis of non‐pharmacological interventions attempted prior to pro re nata medication use

The aim of the present study was to elucidate what non‐pharmacological interventions are applied by nursing staff prior to the administration of psychotropic pro re nata (PRN) medication. Best practices would instruct clinical staff to provide non‐pharmacological strategies, such as de‐escalation and skills coaching, as the first response to patient distress, anxiety, or agitation. Non‐pharmacological strategies might be safer for patients, promote more collaborative relationships, and facilitate greater skills development for managing symptoms. The literature has highlighted that poor documentation of pre‐PRN administration interventions has limited our understanding of this practice, but evidence suggests that when this information is available, non‐pharmaceutical approaches are not being attempted in the majority of cases. This is troubling given that, while clinically appropriate in some instances, PRN have been subject to criticism and lack critical evidence to support their use. The current study is a continuation of our previous work, which examined the reason, frequency, documentation, and outcome (e.g. effectiveness, side‐effects) of PRN medication use at our facility. A chart review was conducted to understand what happens prior to the administration of PRN medication at our facility across all inpatient units over the course of 3 months. Results support previous findings that non‐pharmacological interventions are poorly documented by front‐line staff and are seemingly used infrequently. The use of these interventions differs by patient presentation (e.g. agitation, insomnia), and most often include supportive measures. The findings suggest that both documentation and intervention practices of nursing staff require further investigation and adjustment to align with best practices.     

Developing an Evidence-Based Nursing Protocol Using Early Epinephrine Administration for Anaphylaxis Caused by Computed Tomography Contrast Agents

The objective of this study is to develop an evidence-based nursing practice protocol to cope with anaphylaxis by identifying the effect of early administration of epinephrine on the recovery of patients when anaphylaxis occurs due to computed tomography (CT) contrast agents, and to evaluate its feasibility. Anaphylaxis caused by CT contrast agents is a life-threatening systemic hypersensitivity reaction compared to normal allergic reactions, requiring immediate administration of epinephrine and other emergency drugs; however, no practical guidelines have been established for such emergency management, requiring the development of evidence-based nursing practice protocols. The study design is a methodological and cross-sectional study that aims to develop an evidence-based nursing practice protocol. An evidence-based nursing practice protocol for anaphylaxis management generated by contrast agents was developed in accordance with the 3-step (12 more specific steps) development of clinical practice guideline based on the literature of the final 12 selected (including 2 guidelines). It was applied to practice after implementing the training of the medical staff on the final protocol developed, and evaluated the effectiveness of anaphylaxis management for 6 months before and after the application of the protocol. Based on the analysis of the evidence, we make six recommendations for managing anaphylaxis caused by contrast agents based on early administration of epinephrine and apply the protocol to clinical practice. After protocol application, awareness of anaphylaxis and onset time of epinephrine administration was accelerated, but significant differences were not confirmed. In the case of anaphylaxis due to CT contrast agents, evidence-based coping protocols were created. The developed protocol should be continued for use in practice, with continued assessment of its effectiveness.     

Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use

ACCESSIBLE SUMMARY: This paper reports on a piece of research which is summarized below. ? This research explored how mental health inpatient staff, (including nurses, doctors and other professional disciplines) experience caring for patients who both have mental health problems and who use illicit drugs. (Illicit drugs are illegal drugs which incur a criminal prosecution for possession and/or use). The results of the study were gathered from questionnaires and interviews which asked staff about their viewpoints and experiences. ? The questionnaire results included a section which measured staff attitude towards patients who use illicit drugs and who have mental health problems. Staff who had received training in how to work with people with these problems were found to have a less negative attitude towards these patients. The length of time staff members had worked in their posts or had worked in a particular setting did not have any effect on their attitude. For example, their attitude was not more or less negative towards patients with these problems. ? Ten members of staff were interviewed to find out more in-depth information about their viewpoints and experiences. Overall, these staff members reported a lack of training, difficulty in accessing support and problematic issues within the teams they worked. ? This paper highlights the importance of training to support staff in working with mental health patients who use illicit drugs; and how this affects staff attitude positively towards patients with these problems. ABSTRACT: The extent of illicit substance use within inpatient mental health settings is becoming a major cause of concern. This poses growing challenges not only for the management of inpatient units, but also for providing continuity of care. Service users with co-occurring substance use are more likely to disengage from services. The process of engagement can be hindered by negative attitudes of staff. This study aimed to identify and explore multidisciplinary staff attitudes and experiences in caring for inpatients with co-occurring ill-mental health problems and illicit substance use. A questionnaire incorporating the Drug and Drugs Problems Perceptions Questionnaire (DDPPQ) was used with a non-probability sample of 84 multidisciplinary staff working on nine mental health units. Semi-structured interviews were then carried out with 10 members of staff. Overall, respondents reported: lack of training; difficulty in accessing support structures; and problematic issues with multidisciplinary decision making and processes. The DDPPQ results showed that staff who had received training held less negative attitudes towards illicit substance users regardless of their length of clinical work experience or type of work setting. Recommendations are made about the importance of training and staff support for the development of less negative attitudes towards this client group.     

Prone positioning in acute respiratory failure: survey of Belgian ICU nurses

OBJECTIVE:To determine the frequency of use and attitudes towards prone positioning in patients with acute respiratory failure.DESIGN AND SETTING:Verbal questionnaire survey in all 79 intensive care units in French-speaking Belgium.METHODS:Of the 79 ICUs 29 performed prone-positioning, and 25 agreed to participate in the questionnaire.MEASUREMENTS AND RESULTS:Nurses at 9 of the 25 hospitals expressed reluctance to use prone positioning. The time schedules associated with prone positioning varied among the units surveyed, with no consensus. Units used two to six members of staff to turn a patient, with three most commonly being employed. Patients were most commonly positioned with both arms above the head and cushions under the chest, head, and legs, but there was considerable variation among units. The complications most commonly reported were facial edema and decubitus ulcers, with only three of the units reporting accidental extubation. Only two of the units had an established protocol for prone positioning although nurses from 14 of the units felt this would be useful.CONCLUSIONS:Prone positioning is approached with some reluctance by ICU staff. If the use of prone positioning in patients with acute respiratory distress syndrome is deemed worthwhile, discussion and development of departmental protocols may facilitate its use.     

Challenges of implementing a feasibility study of acupuncture in acute and critical care settings

A majority of people in the United States use complementary and alternative therapies, and this use is increasing. With the increasing interest, providers must evaluate potential risks and benefits of these therapies. This article describes challenges of a feasibility study of acupuncture as a potential therapeutic adjunct to prevent atrial fibrillation following coronary artery bypass graft surgery. Institutional review board approval, consent logistics, implementation issues, and rapid changes in clinical practice were the primary challenges faced. Unique technological features of the institution helped address these challenges. The study protocol was acceptable to staff, patients, and family and was considered safe for these patients. However, the protocol was not feasible as designed; therefore, the efficacy of acupuncture could not be determined. Continued research is needed to evaluate the effectiveness of acupuncture to prevent atrial fibrillation following coronary artery bypass graft surgery. Recommendations for future studies of complementary and alternative therapies in acute and critical care settings are offered.     

Policies and procedures: a tool to support the implementation of clinical guidelines?

OBJECTIVES: To explore the use of policies and procedures as a tool to support the implementation of clinical guidelines and to determine the relationship between organizational support and stability with nurses' perception of policy change. DESIGN: Secondary analysis of qualitative and quantitative data collected in the post-intervention phase of the study entitled Evaluation of the Dissemination and Utilization of Best Practice Guidelines by Registered Nurses in Ontario. SETTING: Eleven agencies across Ontario, Canada. PARTICIPANTS: Fifty nursing staff, 32 nurse administrators and 22 clinical resource nurses (90% response) participated in semi-structured interviews. A total of 316 randomly selected nursing staff from 23 participating units in 11 agencies completed questionnaires (65% response). METHODS: Qualitative data from semi-structured interviews were examined to determine whether participants had modified their policies and procedures as part of the implementation of clinical guidelines. Using SPSS 11.0 for Windows, the authors assessed, using independent t-tests, the relationship between the perception of modification of policies and procedures and the perceptions of organizational support an organisational stability. RESULTS: While modifications to policies and procedures were made at each agency as part of the implementation of clinical guidelines, 27% of staff disagreed that modifications had been made. Nursing staff who agreed that changes had been made to policies and procedures were significantly more likely to report positive organizational support for clinical guideline implementation. CONCLUSION: Findings suggest the need to increase nursing staffs' awareness of changes to policies and procedures during clinical guideline implementation. Furthermore, results indicate that organizational support may have a positive influence on modifications to policies and procedures that are guided by research-based clinical guideline recommendations.     

Improving payments for Medicare patients with unrelated surgical procedures

The Medicare prospective payment system (PPS) pays hospitals a fixed payment for patients in 474 categories of diagnosis-related groups (DRGs). Since the beginning of PPS, many DRGs have been modified to improve the accuracy of patient classification and the equity of hospital payments. There are continuing problems, however, in classifying surgical patients who have no procedure related to their reason for admission. Until recently, these patients were classified into a single miscellaneous category (DRG 468) and paid the same amount, despite considerable variation in their clinical conditions and resource use. Three options for improving the payment and classification of such cases were examined. Improvements are possible using each of the options examined. The greatest improvement, however, was achieved by reassigning patients to existing surgical DRGs, because patients with the same surgery tend to have similar costs, regardless of their original reason for entering the hospital. This change in assignment methodology would increase payments to teaching hospitals, where the most costly DRG 468 cases are concentrated. It also would remove potential incentives to deny access to or withhold appropriate treatments from patients needing high-cost surgical procedures. It was concluded that this change should be implemented for hospital payment under PPS.     

Design of trials with dying patients: a feasibility study of cluster randomisation versus randomised consent

There is little rigorous evidence to underpin clinical guidelines for palliative care. However, research in palliative care is difficult, especially with dying patients. Consent is a major issue, since staff do not wish to invite dying patients to participate in trials. We, therefore, conducted a feasibility study in two units within the North West Wales NHS Trust. We explored two novel approaches to research in palliative care -cluster randomisation and randomised consent. All patients admitted to the two units during the study were asked for permission to use their data for research. We allocated the two units, at random, to use cluster randomisation or randomised consent for three months, and then to crossover to the other design. Of 24 patients dying during cluster-randomised phases, 13 gave consent on admission to use their data and were, thus, eligible to enter the trial; however, defined eligibility criteria reduced these to six active participants. Of 29 patients dying during randomised consent phases, seven gave consent on admission to use their data; although two were eligible for randomisation, neither entered the trial. We judge that cluster randomisation is the more effective design for research with dying patients. Computer simulation, based on data from 1500 dying patients on the Welsh Integrated Care Pathway, shows that crossover cluster trials need much smaller samples than simple cluster trials. Furthermore, this study has shown that crossover cluster trials are entirely feasible. We recommend a 'definitive' trial to test the crossover design more widely.     

Dollars and sense: the economics and outcomes of patients undergoing carotid endarterectomy at Royal Adelaide Hospital.

This study examined the costs and outcomes of patients undergoing carotid endarterectomy who returned directly to the vascular unit after surgery rather than to the intensive care unit (ICU)/high dependency unit (HDU). The ICU/HDU is for critically ill patients. HDU is the step-down area from the ICU. The nurse-to-patient ratio for these patients is 1:2 and senior medical staff are available 24 hours a day. To prepare staff for the change in practice, an intense educational program was provided and protocols for patient management were developed and implemented. Outcomes were then monitored for the group of patients who returned directly to the vascular unit. Case notes audits, informal patient interviews, daily monitoring of patient outcomes, and an analysis of costing data from Australian Diagnostic Related Groups demonstrated that 50% of patients required transfer to the ICU/HDU after surgery for respiratory, hemodynamic, or neurologic management. The remaining 50% of patients returned directly to the vascular unit with no major complications and had better outcomes with less intensive nursing care overall. The length of hospital stay and the management costs were reduced significantly.     

Effects of a stroke rehabilitation education programme for nurses

AIMS: This paper reports a study which aimed to explore the effects of education on the practice of nurses working in stroke rehabilitation units. BACKGROUND: It has been suggested that a key component of the success of stroke units in reducing mortality and disability is the contribution made by nurses, but debate continues around their specific role. Literature has concentrated on nurses' perceptions of their role rather than their actual activities with patients. In studying the effects of education on nurses' practice with stroke patients there is a need to identify what nurses actually do, rather than what they say they do. METHODS: A quasi-experimental, non-equivalent control group design was used to study two stroke rehabilitation units. Non-participant observation was conducted during morning care sessions, focusing on styles of physical interaction. Base-line observations were recorded in each unit, after which the staff in the intervention unit received 7 hours' education, specifically focused on therapeutic handling in relation to morning care activities. Following this, postintervention observations were conducted and comparisons of interaction styles made between units. RESULTS: Twenty-six staff and 37 patients took part in the study. Following the education, staff in the intervention unit showed a change in physical interaction style more in line with therapeutic practice, with the proportion of 'doing for' interventions reducing (45.4% vs. 33.2%; P < 0.05). The proportion of facilitatory interventions increased (3.9% vs. 6.1%) however, this difference was not statistically significant (P = 0.098). The change in styles of practice was achieved with no increased demand on nurses' time. CONCLUSION: Education for nurses which aims to change styles of interaction with stroke patients can be effective. However, further research is required to identify the effect of nursing interventions on patient outcomes following stroke.     

‘Best clinical practice’: assessment of processes of care and of outcomes in the US Military Health Services System

The National Quality Management Program of the Military Health Services System of the United States has undertaken a series of projects whose objective is the active, on-going monitoring and improvement of the effectiveness and efficiency of the care provided to a broad population that encompasses troops on active duty, retirees and dependents. The analytic activities consist of (1) identification by clinical panels of conditions and procedures of interest; (2) collection of data from electronic repositories and from charts to characterize the patients, how they are managed, the clinical outcomes they experience, the resource costs their care entails, and, from questionnaires, their functional status and level of satisfaction, and (3) generation of ‘report cards’ that inform organizational units down to the level of the hospital of the characteristics of their patients, their practices, and the risk-adjusted outcomes they achieve. The patterns of care employed by the hospitals that obtain the best risk-adjusted outcomes and resource utilization (‘best clinical practice’) are identified and made known. In addition, (4) a systematic process of developing outcomes-based practice guidelines has been devised. Its intent is to serve as a decision-support tool for clinicians. Initial estimates have been obtained of the probable consequences of the application of this tool to operative interventions in childbirth. Use of the tool would result in a higher occurrence of elective Caesarean sections, a reduced rate of emergency Caesarean sections and much lower use of forceps, with an overall improvement in outcomes and lower resource costs. This program is currently in the early phases of implementation. The two principal requirements for the immediate future are (1) education of the clinical and administrative communities in the use of the data and the decision-support tools and (2) evaluation of the consequences of the use of the data by the clinical and administrative communities.