***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Introduction While only 15–20 % of patients with foot and ankle injuries presenting to urgent care centers have clinical ly significant fractures , most undergo radiography . We examined the impact of electronic point-of-care clinical decision support ( CDS ) on adherence to the Ottawa Ankle Rules ( OAR ) , as well as use and yield of foot and ankle radiographs in patients with acute ankle injury . Methods We obtained institutional review board approval for this r and omized controlled study performed April 18 , 2012—December 15 , 2013 . All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were r and omized to either receive or not receive CDS , based on the OAR and integrated into the physician order-entry system , with feedback at the time of imaging order . If the patient met OAR low-risk criteria , providers were advised against imaging and could either cancel the order or ignore the alert . We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports review ed for those who were eligible . Chi-square was used to compare adherence to the OAR ( primary outcome ) , radiography utilization rate and radiography yield of foot and ankle imaging ( secondary outcomes ) between the intervention and control groups . Results Of 14,642 patients seen at urgent care during the study period , 613 ( 4.2 % , representing 632 visits ) presented with acute ankle injury and were eligible for application of the OAR ; 374 ( 59.2 % ) of these were seen by control-group providers . In the intervention group , CDS adherence was higher for both ankle ( 239/258=92.6 % vs. 231/374=61.8 % , p=0.02 ) and foot radiography ( 209/258=81.0 % vs. 238/374=63.6 % ; p<0.01 ) . However , ankle radiography use was higher in the intervention group ( 166/258=64.3 % vs. 183/374=48.9 % ; p<0.01 ) , while foot radiography use ( 141/258=54.6 % vs. 202/374=54.0 % ; p=0.95 ) was not . Radiography yield was also higher in the intervention group ( 26/307=8.5 % vs. 18/385=4.7 % ; p=0.04 ) . Conclusion Clinical decision support , previously demonstrated to improve guideline adherence for high-cost imaging , can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increased imaging yield INTRODUCTION In December 2005 , up date d resuscitation Guidelines ( G ) were introduced worldwide and will be revised again in 2010 . This study sought to eluci date how long it takes to implement new guidelines . METHODS This was a prospect i ve observational study . From July 2005 to January 2008 , we included all patients with an out-of-hospital cardiac arrest of suspected cardiac cause . We analyzed Emergency Medical System ( EMS ) Guideline usage via defibrillator recordings of the continuous ECG and impedance signals . We excluded patients with missing or otherwise unusable ECGs . All shocks and CPR cycles were individually classified . The same Guideline needed to be applied for at least 75 % of all shocks and CPR cycles . If no shocks had been given , continuous ECGs were classified by its CPR status only . Continuous ECGs  were classified as G1992 , G2000 or G2005 . If at least 75 % of the shocks were given according to G2000 and at least 75 % of the CPR was according to G2005 , the Guideline protocol was classified as intermediate . All analyses that did not fulfil any Guideline criteria were classified as indeterminate . RESULTS Of 1672 analyzable resuscitations , 31 ( 2 % ) used G1992 , 826 ( 49 % ) G2000 , 608 ( 36 % ) G2005 , and 125 ( 7 % ) intermediate Guidelines . The Guideline protocol could not be identified for the remaining 81 ( 5 % ) patients . It took 17 months ( from publication ) until EMS personnel applied GL2005 in over 80 % of cases . CONCLUSION Our experience shows it took one- and -a-half years to effectively implement new resuscitation Guidelines . We believe improvements in implementation can shorten this to six months OBJECTIVE The purpose of this study was to assess whether implementing emergency department ( ED ) physician performance feedback reports improves adherence to evidence -based guidelines for use of CT for evaluation of pulmonary embolism ( PE ) beyond that achieved with clinical decision support ( CDS ) alone . SUBJECTS AND METHODS This prospect i ve r and omized controlled trial was conducted from January 1 , 2012 , to December 31 , 2013 , at an urban level 1 adult trauma center ED . Attending physicians were stratified into quartiles by use of CT for  evaluation of PE in 2012 and were r and omized to receive quarterly feedback reporting or not , beginning January 2013 . Reports consisted of individual and anonymized group data on guideline adherence ( using the Wells criteria ) , use of CT for PE ( number of CT examinations for PE per 1000 patients ) , and yield ( percentage of CT examinations for PE with positive findings ) . We compared guideline adherence ( primary outcome ) and use and yield ( secondary outcomes ) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012 . RESULTS Of 109,793 ED patients during the control and intervention periods , 2167 ( 2.0 % ) underwent CT for evaluation of PE . In the control group , guideline adherence remained unchanged between 2012 ( 78.8 % [ 476/604 ] ) and 2013 ( 77.2 % [ 421/545 ] ) ( p = 0.5 ) ; in the intervention group , guideline adherence increased 8.8 % after feedback report implementation , from 78.3 % ( 426/544 ) to 85.2 % ( 404/474 ) ( p < 0.05 ) . Use and yield were unchanged in both groups . CONCLUSION Implementation of quarterly feedback reporting result ed in a modest but significant increase in adherence to evidence -based guidelines for use of CT for evaluation of PE  in ED patients , enhancing the impact of CDS alone . These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence INTRODUCTION Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non- clinical or traditional testing manner . Such surrogate outcomes may not necessarily reflect vital changes in practice . The aim of this study was to determine if and to what extent , specific training in the management of life threatening emergencies result ed in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan . METHODS A cluster r and omised controlled trial was conducted in three districts hospitals in three cities ( Khairpur , Vehari and Peshawar ) of Pakistan . Thirty-six doctors , 18 in intervention ( trained in ESS-EMNCH training ) and 18 in control ( untrained ) , were enrolled and 248 life threatening emergency events , 124 in each group , were observed for the correct use of the Airway , Breathing , Circulation ( ABC ) structured approach . The outcome measure was structured approach defined a priori . Data was analysed by using STATA software . RESULTS At individual level , 79 ( 63.7 % ) life threatening episodes were managed according to the structured approach in the intervention group and 46 ( 37.1 % ) were managed according to the structured approach in controls ( OR 2.98 , 95%CI 1.78 - 4.99 , p-value=0.0001 ) . At cluster level , the mean percentage ( 95 % CI ) of the structured approach used by doctors in the intervention group [ 62.9 % ( 50.4 - 75.3 % ) ] , was significantly higher than those in the control group , [ 36.3 % ( 26.3 - 46.4 ) ] ( p-value=0.001 ) . CONCLUSIONS 5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan Background —American College of Cardiology/American Heart Association guidelines recommend > 75 % of patients with an ST-elevation myocardial infa rct ion receive primary percutaneous coronary interventions ( PPCI ) within 90 minutes . Despite these recommendations , this goal has been difficult to achieve . Methods and Results —We conducted a prospect i ve interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infa rct team on door-to-balloon time ( D2BT ) . The median D2BT of all patients ( n=107 ) who underwent PPCI after field ECG and emergency department activation of the infa rct team ( MonashHEART Acute Myocardial Infa rct ion [ MonAMI ] group ) was 56 minutes ( interquartile range , 36.5 to 70 ) compared with the median time of a contemporary group ( n=122 ) undergoing PPCI during the same period but not receiving field triage ( non-MonAMI group ) of 98 minutes ( 73 to 126.45 ) . The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project ( pre-MonAMI group ) was 101.5 minutes ( 72.5 to 134 ; P<0.001 ) . The proportion of patients who achieved a D2BT of ≤90 minutes increased from 39 % in the pre-MonAMI group and 45 % in the non-MonAMI group to 93 % in the MonAMI group ( P<0.001 ) . Conclusions —The performance of prehospital 12-lead ECG triage and emergency department activation of the infa rct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations Abstract Acute gastroenteritis ( AGE ) is one of the most frequent reasons for young children to visit emergency departments ( EDs ) . We aim ed to evaluate ( 1 ) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and ( 2 ) the impact on diagnostics , treatment , and costs compared with usual care by attending physician . A r and omized controlled trial was performed in 222 children , aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children ’s hospital in The Netherl and s ( 2010–2012 ) . Outcome included ( 1 ) feasibility , measured by compliance of the nurses , and ( 2 ) length of stay ( LOS ) at the ED , the number of diagnostic tests , treatment , follow-up , and costs . Due to failure of post-ED weight measurement , we could not evaluate weight difference as measure for dehydration . Patient characteristics were comparable between the intervention ( N = 113 ) and the usual care group ( N = 109 ) . Implementation of the clinical decision support system proved a high compliance rate . The st and ardized use of oral ORS ( oral rehydration solution )  significantly increased from 52 to 65%(RR2.2 , 95%CI 1.09–4.31 p < 0.05 ) . We observed no differences in other outcome measures . Conclusion : Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase st and ardized use of ORS , without differences in other outcome measures .What is Known:• Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments.• Guidelines advocate st and ardized oral treatment in children with mild to moderate dehydration , but appear to be applied infrequently in clinical practice .What is New:• Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility , result ing in a more st and ardized ORS use in children with mild to moderate dehydration , compared to usual care.• Given the challenges to perform research in emergency care setting , the ED should be experienced and adequately equipped , especially during peak times INTRODUCTION Emergency nurses deal with increasing complexity of patients . In 2003 there were over 14 million ED visits in Canada . The Canadian Triage and Acuity Scale ( CTAS ) is a 5-level system used by ED triage nurses to classify patients . There is a need for st and ardized training for all triage systems . In an effort to improve access to CTAS training , a 6-week Web-based CTAS workshop was developed . We determined the impact of Web learning on the accuracy of the triage skills of registered nurses ( RNs ) . METHODS An experimental method was used in which 132 RNs were r and omized to an  intervention group ( n = 65 ) or control group ( n = 67 ) . All RNs received exactly the same content and learning activities . 
    Output:
    
For the ED setting , the studies indicated that educational strategies as sole intervention , and educational strategies in combination with audit and feedback , are probably effective in improving guideline adherence .
Sole use of reminders in the ED setting also showed positive effects .
Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care , or the combination of prehospital and ED care .
For ED setting s , the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence