"I really want people to use our work to be safe"…Using participatory research to develop a safety intervention for adults with intellectual disability

People with intellectual disability experience disproportionately high rates of interpersonal violence (IPV) due, in part, to disability-related risks that often can be minimized through targeted intervention. In this article, we describe using an academic and community participatory research approach to develop and test the feasibility of an accessible IPV prevention program for people with intellectual disability. The Safety Class, which is an interactive, structured, eight-session, weekly face-to-face group program, was found feasible for implementation in an efficacy study. Working in partnership with the intellectual disability community through all phases of the project helps ensure the relevance, inclusion, and accessibility of The Safety Class.

Protocol for the process evaluation of the Promoting Activity, Independence and Stability in Early Dementia (PrAISED), following changes required by the COVID-19 pandemic

INTRODUCTION

The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) randomised controlled trial (RCT) is evaluating a home-based, face-to-face, individually tailored, activity and exercise programme for people living with dementia. Social distancing requirements following the COVID-19 pandemic necessitated rapid changes to intervention delivery.

METHODS AND ANALYSIS

A mixed-methods process evaluation will investigate how the changes were implemented and the impact that these have on participants' experience. An implementation study will investigate how the intervention was delivered during the pandemic. A study on the mechanisms of impact and context will investigate how these changes were experienced by the PrAISED participants, their carers and the therapists delivering the intervention. The study will commence in May 2020.

ETHICS AND DISSEMINATION

The PrAISED RCT and process evaluation have received ethical approval number 18/YH/0059. The PrAISED process evaluation will enable us to understand how distancing and isolation affected participants, their activity and exercise routines and whether the therapy programme could be continued with remote support. This will be valuable both in explaining trial results and also contribute to understanding and designing new ways of delivering home-based services and rehabilitation interventions for people with dementia and their carers.

TRIAL REGISTRATION NUMBER

ISRCTN15320670; Pre-results.

A work system analysis of the medication administration process in a Norwegian nursing home ward

Nursing home patients often have multiple diagnoses and a high prevalence of polypharmacy and are at risk of experiencing adverse drug events. The study aims to explore the dynamic interactions of stakeholders and work system elements in the medication administration process in a nursing home ward. Data were collected using observations and interviews. A deductive content analysis led to a SEIPS-based process map and an accompanying work system analysis. The study increases knowledge of the complexity of the medication administration process by portraying the dynamic interactions between the major stakeholders in the work system, and the temporal flow of the activities involved. Secondly, it identifies facilitators and barriers in the work system linked to the medication administration process. Most barriers and facilitators are associated with the work system elements - tools & technology, organisation and tasks - and occur early in the medication administration process.

Evaluating process fidelity during the implementation of Group Antenatal Care in Mexico

BACKGROUND

CenteringPregnancy (CP) is a group antenatal care (G-ANC) model that has proven beneficial for mothers and their newborns. We conducted a feasibility study beginning in 2016 as part of the Mexican effort to implement G-ANC locally. This study reports on fidelity to the essential elements of CP during its implementation in Mexico.

METHODS

We collected prospective data using a standardized checklist at four primary-care centers that implemented our adapted G-ANC model. We performed a descriptive analysis of fidelity to 28 processes per G-ANC session (71 sessions made up of 10 groups and 129 women across 4 health centers). We calculated fidelity to each process as a proportion with 95% confidence intervals. We present overall results and stratified by health center and by facilitation team.

RESULTS

Overall fidelity to the G-ANC intervention was 82%, with variability by health center (78-88%). The elements with the highest fidelity were having space for activities such as checking vital signs, conversation in a circle, and medical check-ups (100% each) and the element with the lowest fidelity was using music to enhance privacy (27.3%). Fidelity was not significantly different by center.

CONCLUSIONS

Our study suggests good model fidelity during the implementation of G-ANC in Mexico. Our findings also contribute useful information about where to focus efforts in the future to maintain and improve G-ANC model fidelity.

Modified Anesthesia Protocol for Electroconvulsive Therapy Permits Reduction in Aerosol-Generating Bag-Mask Ventilation during the COVID-19 Pandemic

INTRODUCTION

Electroconvulsive therapy (ECT) is a critical procedure in psychiatric treatment, but as typically delivered involves the use of bag-mask ventilation (BMV), which during the COVID-19 pandemic exposes patients and treatment staff to potentially infectious aerosols.

OBJECTIVE

To demonstrate the utility of a modified anesthesia protocol for ECT utilizing preoxygenation by facemask and withholding the use of BMV for only those patients who desaturate during the apneic period.

METHODS

This chart review study analyzes patients who were treated with ECT using both the traditional and modified anesthesia protocols.

RESULTS

A total of 106 patients were analyzed, of whom 51 (48.1%) required BMV using the new protocol. Of clinical factors, only patient BMI was significantly associated with the requirement for BMV. Mean seizure duration reduced from 52.0 ± 22.4 to 46.6 ± 17.1 s, but seizure duration was adequate in all cases. No acute physical, respiratory, or psychiatric complications occurred during treatment.

CONCLUSIONS

A modified anesthesia protocol reduces the use of BMV by more than 50%, while retaining adequate seizure duration.

Understanding implementation success: protocol for an in-depth, mixed-methods process evaluation of a cluster randomised controlled trial testing methods to improve detection of Lynch syndrome in Australian hospitals

INTRODUCTION

In multisite intervention trials, implementation success often varies widely across settings. Process evaluations are crucial to interpreting trial outcomes and understanding contextual factors and causal chains necessary for successful implementation. Lynch syndrome is a hereditary cancer predisposition conferring an increased risk of colorectal, endometrial and other cancer types. Despite systematic screening protocols to identify Lynch syndrome, the condition remains largely underdiagnosed. The Hide and Seek Project ('HaSP') is a cluster randomised controlled trial determining the effectiveness of two approaches to improving Lynch syndrome detection at eight Australian hospital networks. To enhance widespread implementation of optimal Lynch syndrome identification, there is a need to understand not only what works, but also why, in what contexts, and at what costs. Here we describe an in-depth investigation of factors influencing successful implementation of procedures evaluated in the HaSP trial.

METHODS AND ANALYSIS

A mixed-methods, theory-driven process evaluation will be undertaken in parallel to the HaSP trial. Data will include: interviews of Implementation Leads and Lynch syndrome stakeholders, pre-post implementation questionnaires, audio analysis of meetings and focus groups, observation of multidisciplinary team meetings, fidelity checklists and project log analysis. Results will be triangulated and coded, drawing on the Theoretical Domains Framework, Consolidated Framework for Implementation Research and Proctor's implementation outcomes.

ETHICS AND DISSEMINATION

Use of a theory-based process evaluation will enhance interpretation and generalisability of HaSP trial findings, and contribute to the implementation research field by furthering understanding of the conditions necessary for implementation success. Ethical approval has been granted and results will be disseminated via publications in peer-reviewed journals and conference presentations. At trial completion, key findings will be fed back to sites to enable refinement of intervention strategies, both in the context of Lynch syndrome and for the possible generalisability of intervention components in other genetic and broader clinical specialties.

HASP TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (Identifier: ACTRN12618001072202). Registered 27 June 2018. http://www.ANZCTR.org.au/ACTRN12618001072202.aspx.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

OBJECTIVE

Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated.

METHODS

Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test.

RESULTS

More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02).

CONCLUSIONS

A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

Building an Expanded Therapeutic Alliance: A Task Analysis with Families Trapped in Parental-Adolescent Conflict

Parental-adolescent conflict is part of the normal developmental cycle of families, but when it occurs in a dysfunctional way, it is associated with the appearance of various harmful conditions for the family system and for the adolescent in particular. Family therapy is one of the main options for psychotherapeutic intervention in these cases and has ample evidence of its effectiveness. The success of this intervention is conditioned to the construction of an adequate therapeutic alliance with the family, but the process of this task has not been clarified yet. The present study is a task analysis, the purpose of which was to create a heuristic model of how an expanded alliance may be built in these kinds of cases. The model was revised and improved from the intensive analysis of six cases. The resulting model can be a useful guide for family therapists in that it describes the specific client and therapist behaviors involved in balancing the alliance, as well as the potential obstacles and suggested ways to resolve them.

The Cultural Adaptation of a Transition Program for Latino Families of Youth with Autism Spectrum Disorder

During the transition to adulthood, effective and culturally relevant supports are critical for families of youth with autism spectrum disorder (ASD). There is a dearth of documented program development and research on supports for Spanish-speaking Latino families during this life stage. The present work describes the cultural adaptation process of an evidence-based transition program for Latino families of youth with ASD. A model of the actions necessary to meaningfully conduct a cultural adaptation in this context is described. After implementing the culturally adapted program titled Juntos en la Transición with five Spanish-speaking families, parents reported high social validity of the program through surveys and interviews. The cultural adaptation process followed in this work is important for the further development of programs that address the transition needs of Latino youth with ASD and their families. Our impressions may also be useful to those who aim to develop culturally sensitive and ecologically valid multifamily group intervention programs for families from cultural and linguistic minority groups.

A Snapshot of RTI Implementation a Decade Later: New Picture, Same Story

Response to intervention (RTI) has evolved from its first decade of implementation. Because states guide and regulate policy and practice at the state and local education agency levels, it is important to understand their critical role in RTI implementation. A systematic review of all 50 state education agency websites was conducted to provide an updated "snapshot" of states' interpretation of RTI a decade after IDEA regulations were finalized. Findings revealed substantive progress towards developing approaches to systematic supports to students, with a major trend in adoption of multi-tiered system of support (MTSS) models. Findings also documented continued variation in how states are communicating about tiered systems on such matters as the roles of tiered systems in schoolwide prevention frameworks, meeting special education requirements, and aligning multiple systems within schools. Implications for special education services for students with learning disabilities are discussed.

Implementation of an interactive organ donation education program for Dutch lower-educated students: a process evaluation

BACKGROUND

As organ donation registration rates remain low, especially among lower-educated people, it is important to support this group in making their registration decision. To prepare lower-educated students in the Netherlands for making a well-informed decision, an interactive educational program was developed. We aim to understand both the (quality of) implementation as well as to contextualize the effects of this program in a lower-educated school setting.

METHODS

The process evaluation was part of a Cluster Randomized Controlled Trial, in which 11 schools for Intermediate Vocational Education throughout the Netherlands participated. Teachers who taught a course on Citizenship delivered three intervention elements (i.e. video fragments and discussion, quizzes with tailored feedback and an exercise filling out a registration form) to their students. Implementation was assessed by interviews with teachers, questionnaires from students, logbooks from teachers and user data from Google Analytics.

RESULTS

The program was well received and implemented, but on-the-spot adaptations were made by teachers to fit their students better. Within the lower-educated target group, differences between students are high in terms of active participation, reading abilities, knowledge and attention span. The program fit well within their regular teaching activities, but the topic of organ donation is not always prioritized by teachers.

CONCLUSIONS

We see opportunities to disseminate the program on a larger scale and reach a group that has been neglected in organ donation education before. Within the program, there are possibilities to increase the effectiveness of the program, such as alternative delivery methods for the elements with a lot of text, the addition of booster sessions and guidelines for teachers to adapt the program to students of different levels within Intermediate Vocational Education. Moreover, in order to have an impact on a national level, strategies need to be employed to reach high numbers of students and, therefore, support on a higher level is needed (both within schools and at policy level).

TRIAL REGISTRATION

Dutch Trial Register, NTR6771. Prospectively registered on 24 October 2017.

Sexual network distribution of HIV self-testing kits: Findings from the process evaluation of an intervention for men who have sex with men in China

BACKGROUND

The World Health Organization has recommended HIV self-testing (HIVST) as an alternative testing strategy given the limitations of facility-based testing. While the benefits of HIV self-testing have been demonstrated at the individual level among men who have sex with men (MSM), limited data exist on if this testing approach can be effectively diffused through individuals' social or sexual networks. The objectives of this study were to examine patterns and correlates of HIVST distribution within Chinese MSM's sexual networks.

METHODS

Data used for this analysis was a part of the process evaluation of an HIVST intervention trial among MSM in Nanjing, China. Between May and October 2017, we enrolled 400 men into the trial. Participants assigned to the intervention group (N = 200) were given three HIVST kits at baseline and could request more during the follow-up periods. We incorporated measures for process evaluation in the self-administered online follow-up surveys. This analysis reported findings from the three-month follow-up survey in the intervention group. Frequencies and percentages were used to describe characteristics of participants who distributed kits to their sexual partners as well as patterns of distribution. Multivariable logistic regression was conducted to identify independent correlates of participants who distributed the kits.

RESULTS

Of the 177 participants retained (88.5%) at the three-month follow-up, 72 (40.7%) distributed one or more kits to either primary or casual partners. About half of distributors (51.4%) gave one HIVST kit to their sexual partners while 15.3% distributed 3 or more. Over half gave these kits (58.3%) to primary sexual partners while 27.8% reported giving the kits to both primary and casual partners. About half (54.2%) of distributors used the kits together with their partners. Compared to participants who had an HIV test in the past six months, those who tested over six months ago or never tested had significantly lower odds of distributing the kits (AOR = 0.484, 95% CI: 0.250-0.983, p = 0.032). Compared to those who had not used the kits themselves, participants who did had significantly higher odds of distributing the kits (AOR = 3.345, 95% CI: 1.488-7.517, p = 0.003). Participants who reported higher HIV testing efficacy had 2.051 fold greater odds (95% CI: 1.062-3.961, p = 0.033) of distributing the kits compared to those who had lower efficacy.

CONCLUSION

Our study demonstrated that a sexual network-based approach to distributing HIVST among Chinese MSM is feasible and can be a promising strategy to improve the effectiveness of HIVST programs including its reach to untested men. Such approach should be complimented by intervention components that enhance HIV testing efficacy and improve experiences of HIVST.

Improving the participation of adults with visual and severe or profound intellectual disabilities: a process evaluation of a new intervention

BACKGROUND

While the participation of adults with visual and severe or profound intellectual disabilities (VSPID) in society and community life is important, evidence-based interventions to improve their participation are lacking. We conducted a process evaluation of the implementation of 'Care for Participation+' (CFP+), a new intervention targeting the attitudes of direct support professionals (DSPs) toward the participation of adults with VSPID, within a residential facility in the Netherlands.

METHODS

CFP+ was inspired by the Boston Psychiatric Rehabilitation Approach and adapted by adopting a new definition and operationalization of the concept of participation for adults with VSPID. Following systematic training, 16 DSPs of adults with VSPID were able to apply key elements of CFP+ to explore diverse roles and activities for this population, facilitating their self-management, teaching them necessary skills for participation, and organizing support. Our process evaluation entailed an investigation of the delivered dose, reach, fidelity, and adaptation of CFP+ during and after the CFP+ intervention. We also evaluated the mechanisms of impact and context using questionnaires, assignments, documentation, interviews, and a logbook.

RESULTS

The intended dose, reach, and fidelity relating to the implementation of CFP+ were not achieved. Despite this fact, an assessment of the mechanisms of impact indicated that assignments of CFP+ were well (75%) or reasonably well (17%) understood by DSPs. CFP+ was applied by DSPs to stimulate self-management (83% of DSPs), new activities (100%), enhanced involvement in existing activities (67%) and to explore new roles (50%) for adults with VSPID. A negative contextual factor mentioned by the trainer and manager was the DSPs' lack of commitment to the training program. Another negative contextual factor mentioned by DSPs was the lack of time for implementing CFP+.

CONCLUSIONS

CFP+ provides new opportunities to improve the participation of adults with VSPID. Despite the non-optimal conditions for implementing CFP+ and the DSPs' general reluctance to apply the new intervention, some have actively used CFP+ within the residential facility. Future studies should focus on the outcomes of CFP+ regarding attitudinal changes among DSPs relating to the participation of adults with VSPID and their quality of life.

Facilitators of and barriers to reducing thirty-day readmissions and improving patient-reported outcomes after surgical aortic valve replacement: a process evaluation of the AVRre trial

BACKGROUND

The Aortic Valve Replacement Readmission (AVRre) randomized control trial tested whether a telephone intervention would reduce hospital readmissions following surgical aortic valve replacement (SAVR). The telephone support provided 30 days of continuous phone-support (hotline) and two scheduled phone-calls from the hospital after discharge. The intervention had no effect on reducing 30-day all-cause readmission rate (30-DACR) but did reduce participants' anxiety compared to a control group receiving usual care. Depression and participant-reported health state were unaffected by the intervention. To better understand these outcomes, we conducted a process evaluation of the AVRre trial to gain insight into the (1) the dose and fidelity of the intervention, (2) mechanism of impacts, and (3) contextual factors that may have influenced the outcomes.

METHODS

The process evaluation was informed by the Medical Research Council framework, a widely used set of guidelines for evaluating complex interventions. A mix of quantitative (questionnaire and journal records) and qualitative data (field notes, memos, registration forms, questionnaire) was prospectively collected, and retrospective interviews were conducted. We performed descriptive analyses of the quantitative data. Content analyses, assisted by NVivo, were performed to evaluate qualitative data.

RESULTS

The nurses who were serving the 24/7 hotline intervention desired to receive more preparation before intervention implementation. SAVR patient participants were highly satisfied with the telephone intervention (58%), felt safe (86%), and trusted having the option of calling in for support (91%). The support for the telephone hotline staff was perceived as a facilitator of the intervention implementation. Content analyses revealed themes: "gap in the care continuum," "need for individualized care," and "need for easy access to health information" after SAVR. Differences in local hospital discharge management practices influenced the 30-DACR incidence.

CONCLUSIONS

The prospective follow-up of the hotline service during the trial facilitated implementation of the intervention, contributing to high participant satisfaction and likely reduced their anxiety after SAVR. Perceived less-than-optimal preparations for the hotline could be a barrier to AVRre trial implementation. Integrating user experiences into a mixed-methods evaluation of clinical trials is important for broadening understanding of trial outcomes, the mechanism of impact, and contextual factors that influence clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02522663. Registered on 11 August 2015.

Direct access surgery for cholecystectomy - can we speed up the process?

BACKGROUND

In appropriate patients, direct referral from general practitioners to surgery without pre-operative clinic assessment can streamlining the process and allow more efficient use of clinical time. This study aimed to look at the feasibility of a direct access cholecystectomy pathway in patients with symptomatic gallstones and their satisfaction of it.

METHODS

In 2012, Bay of Plenty general practitioners (GP) were invited to refer fit patients (ASA 1 or 2, BMI <35 and <60 years old) with symptomatic cholelithiasis directly to a surgical list. One surgeon oversaw each referral and the process. The patients GP provided written and visual information and pre-operative health preoperative health questionnaire. Patients presented on the day of surgery, were seen, consented and underwent day stay cholecystectomy. Post-operative follow up was GP lead.

RESULTS

41 patients were referred via the Direct Access Surgery pathway. 37 patients were deemed appropriate with 35 proceeded to surgery. Waiting time from referral to operation was reduced from 120 (standard pathway) to 59.3 days. 30 patients (86%) had day stay procedures. Three patients (8%) re-presented with ongoing right upper quadrant pain within one year requiring further investigation. A written voluntary questionnaire was sent to all patients who underwent DAS with an 80% response rate. Overall the majority of patients (24/28; 85%) agreed or strongly agreed that they felt fully informed regarding the operation and were happy with the process.

CONCLUSION

Direct Access Surgery is an effective way to streamline healthy patients' access to operative intervention.

Process evaluation of a tailored workplace intervention designed to promote sustainable working in a rapidly changing world

Increasing numbers of people are employed in sedentary occupations, spending large amounts of time sitting at work which is detrimental to health and wellbeing. Evidence-based guidance is required to intervene to reduce sedentary behaviour, encourage physical activity and promote sustainable working. This article presents a process evaluation of a successful workplace intervention Walking Works Wonders, shown to be effective in improving health, job satisfaction and motivation (Haslam et al. 2018). In this qualitative process evaluation employees reported an increased awareness of their sedentary time and they particularly valued the monitoring of activity using pedometers. They described changes to their working and leisure time activity to accumulate more steps. Participants reported improved physiological and psychological health outcomes, improved working relations with colleagues, changes in dietary behaviour and involving their families in physical activity. The results highlight elements of the intervention that encouraged healthy and more sustainable working practices.Practitioner summary: This study provides the employees' perspective on the effective elements of a workplace intervention which encouraged physical activity and reduced sitting time. The results offer valuable insights for practitioners aiming to develop interventions to improve health and facilitate more sustainable working practices in a rapidly changing world of work.Abbreviations: BMI: body mass index; PDF: portable document format.

What Do People With Schizophrenia Do All Day? Ecological Momentary Assessment of Real-World Functioning in Schizophrenia

Schizophrenia is a major cause of disability worldwide. As new treatments for functioning are tested, the need grows to demonstrate real-world functioning gains. Ecological momentary assessment (EMA) may provide a more ecologically valid measure of functioning. In this study, smartphone-based EMA was used to signal participants with schizophrenia (N = 100) and controls (N = 71) 7 times a day for 7 days to respond to brief questionnaires about social interactions and functioning behaviors. Excellent adherence was found, with both groups completing an average of 85% of surveys and only 3% of participants with schizophrenia excluded for poor adherence. Four-week test-retest reliability was high (r = .83 for total productive behaviors). Relative to controls, participants with schizophrenia reported significantly less total productive activity (d = 1.2), fewer social interactions (d = 0.3), more nonproductive behaviors (d = 1.0; watching TV, resting), and more time at home (d = 0.8). Within the schizophrenia group, participants living independently showed better functioning on EMA relative to participants in supported housing (d = 0.8) and participants engaged in vocational activities showed better functioning than individuals not engaged in vocational activities (d = 0.55). Modest correlations were found between EMA and an in-lab self-report measure of functioning activities performed in the community, but not between EMA and measures of functional capacity or potential. This study demonstrated the feasibility, sensitivity reliability, and validity of EMA methods to assess functioning in schizophrenia. EMA provides a much-needed measure of what individuals with schizophrenia are actually doing in real-world contexts. These results also suggest that there may be important disjunctions between indices of abilities and actual real-world functioning.

Assessment of a Best Practice Alert and Referral Process for Preprocedure Antithrombotic Medication Management for Patients Undergoing Gastrointestinal Endoscopic Procedures

IMPORTANCE

Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety.

OBJECTIVE

To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures.

DESIGN, SETTING, AND PARTICIPANTS

This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019.

EXPOSURES

Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017.

MAIN OUTCOMES AND MEASURES

The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level.

RESULTS

A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02).

CONCLUSIONS AND RELEVANCE

A newly implemented BPA and anticoagulation clinic referral process was broadly adopted and used, had high satisfaction by patients and clinicians, and was associated with fewer disruptions to planned procedures caused by medication mismanagement.

Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation

BACKGROUND

Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia.

METHODS

VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425.

FINDINGS

Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes.

INTERPRETATION

Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect.

FUNDING

UK Department of Health and the Wellcome Trust.

Enhancing the Informed Consent Process Using Shared Decision Making and Consent Refusal Data from the CLEAR III Trial

BACKGROUND

The process of informed consent in National Institutes of Health randomized, placebo-controlled trials is poorly studied. There are several issues regarding informed consent in emergency neurologic trials, including a shared decision-making process with the patient or a legally authorized representative about overall risks, benefits, and alternative treatments.

METHODS

To evaluate the informed consent process, we collected best and worst informed consent practice information from a National Institutes of Health trial and used this in medical simulation videos to educate investigators at multiple sites to improve the consent process. Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) (clinicaltrials.gov, NCT00784134) studied the effect of intraventricular alteplase (n = 251) versus saline (placebo) injections (n = 249) for intraventricular hemorrhage reduction. Reasons for ineligibility (including refusing to consent) for all screen failures were analyzed. The broadcasted presentation outlined best practices for doctor-patient interactions during the consenting process, as well as anecdotal, study-specific reasons for consent refusal. Best and worst consent elements were then incorporated into a simulation video to enhance the informed consent process. This video was disseminated to trial sites as a webinar around the midpoint of the trial to improve the consent process. Pre- and post-intervention consent refusals were compared.

RESULTS

During the trial, 10,538 patients were screened for eligibility, of which only three were excluded due to trial timing. Pre-intervention, 77 of 5686 (1.40%) screen eligible patients or their proxies refused consent. Post-intervention, 55 of 4849 (1.10%) refused consent, which was not significantly different from pre-intervention (P = 0.312). The incidence of screen failures was significantly lower post-intervention (P = 0.006), possibly due to several factors for patient exclusion.

CONCLUSION

The informed consent process for prospective randomized trials may be enhanced by studying and refining best practices based on trial-specific plans and patient concerns particular to a study.

Defining and Managing the Preanalytical Phase With FMECA: Automation and/or "Human" Control

OBJECTIVE

Our scope is to provide methodological elements on how to manage effectively the preanalytical phase in the laboratory testing process, by objectively measuring the risk connected to the phases handled by man with respect to those managed by machines.

BACKGROUND

Preanalytical errors account for most of the mistakes related to laboratory testing and can affect patient care. Hence, it is necessary to manage the risk connected to the preanalytical phase, as required by certification and accreditation bodies. The risk assessment discloses the steps at greater risk and gives indications to make decisions.

METHOD

We have reviewed the state of art in the automation of the preanalytical phase, addressing needs and problems. We have used the proactive risk assessment methodology FMECA (Failure Mode, Effects, and Criticality Analysis) to identify the most critical phases in our preanalytical process and have calculated the risk associated.

RESULTS

The most critical phases were the human controlled ones. In particular, the highest risk indexes were associated to manual acceptance of test orders, identification of the patients, tube labeling, and sample collection.

CONCLUSION

Automation in the preanalytical phase is fundamental to replace, support, or extend the human contribution. Nevertheless each organization is different about workloads and competencies, so the most suitable management must be tailor-made in each context.

APPLICATION

We present a method by which each organization is able to find its best balance between automation and human contribution in the control of the preanalytical phase.

Computer-assisted planning for minimally invasive anterior two-thirds laser corpus callosotomy: A feasibility study with probabilistic tractography validation

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Laser interstitial thermal therapy (LITT) is a novel minimally invasive technique for the treatment of epilepsy.

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We test computer assisted planning with LITT to disrupt seizure spread.

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Trajectory parameters and models were automatically generated from a single T1 image.

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Probabilistic tractography revealed comparable interhemispheric disconnection to blinded expert surgeons.

Background

Anterior two-thirds corpus callosotomy is an effective palliative neurosurgical procedure for drug-refractory epilepsy that is most commonly used to treat drop-attacks. Laser interstitial thermal therapy is a novel stereotactic ablative technique that has been utilised as a minimally invasive alternative to resective and disconnective open neurosurgery. Case series have reported success in performing laser anterior two-thirds corpus callosotomy. Computer-assisted planning algorithms may help to automate and optimise multi-trajectory planning for this procedure.

Objective

To undertake a simulation-based feasibility study of computer-assisted corpus callostomy planning in comparison with expert manual plans in the same patients.

Methods

Ten patients were selected from a prospectively maintained database. Patients had previously undergone diffusion-weighted imaging and digital subtraction angiography as part of routine SEEG care. Computer-assisted planning was performed using the EpiNav™ platform and compared to manually planned trajectories from two independent blinded experts. Estimated ablation cavities were used in conjunction with probabilistic tractography to simulate the expected extent of interhemispheric disconnection.

Results

Computer-assisted planning resulted in significantly improved trajectory safety metrics (risk score and minimum distance to vasculature) compared to blinded external expert manual plans. Probabilistic tractography revealed residual interhemispheric connectivity in 1/10 cases following computer-assisted planning compared to 4/10 and 2/10 cases with manual planning.

Conclusion

Computer-assisted planning successfully generates multi-trajectory plans capable of LITT anterior two-thirds corpus callosotomy. Computer-assisted planning may provide a means of standardising trajectory planning and serves as a potential new tool for optimising trajectories. A prospective validation study is now required to determine if this translates into improved patient outcomes.

Feasibility of a school-based exercise intervention for children with intellectual disability to reduce cardio-metabolic risk

BACKGROUND

People with intellectual disabilities (ID) are at increased risk of secondary health conditions, reduced quality of life and life expectancy. Children with ID demonstrate low levels of physical activity in association with a higher prevalence of obesity, a modifiable risk factor associated with secondary health conditions including type 2 diabetes and cardiovascular disease. Despite this, physical activity interventions addressing weight and weight-related complications in this population are limited. This study aimed to establish the feasibility of a school-based group exercise intervention for children with moderate to severe ID.

METHODS

A single-arm intervention study was used to establish the feasibility of a 16-week exercise intervention. Children attending a School for Specific Purposes in Sydney, Australia, participated in two 30-min exercise sessions per week across the intervention period in addition to their regular physical education class. Each exercise session was 60% aerobically based, 20% strength based and 20% targeted towards fundamental movement skill development. We used two facilitation strategies to assist the delivery of the intervention, including the implementation of a variety of communication resources and promotion of social interaction. Feasibility was assessed through recruitment rates, program retention, adverse effects, attendance, group size feasibility and non-compliance. Anthropometric measures included height (m), weight (kg) and waist circumference (cm; umbilicus), with body mass index (BMI) and waist-to-height ratios (WtHR) used to determine cardio-metabolic risk. Aerobic capacity was assessed using the submaximal 6-min walk test (6-MWT). Intensity of physical activity sessions was measured through the use of tri-axial accelerometers and compared to physical activity recommendations.

RESULTS

Ten children aged between 9 and 13 years completed the 16-week intervention, with a 55% recruitment rate, 91% program retention, 86% attendance and with no adverse effects reported. Sessions commenced as 1:1 supervisor to child ratios before progressing to established small groups of 2:7 (supervisor : child). Children spent 38.4% (11.5 min) of each session in moderate to vigorous physical activity (MVPA), equating to 20% of their MVPA recommended daily physical activity levels (twice per week). There was a significant change in weight across the intervention period, with a trend towards increased weight between mid-intervention and 3-month follow-up time points. There were no significant changes in child BMI, WtHR or aerobic capacity.

CONCLUSIONS

A school-based group exercise intervention for children with moderate to severe ID is feasible and safe, with high retention rates and physical activity participation. No significant improvements in body composition or aerobic capacity were determined. The present study demonstrates that engaging children with moderate-severe ID in school-based group exercise is feasible to assist in physical activity participation.

Clinical trial recruitment of adult African American smokers from economically disadvantaged urban communities

This investigation evaluated the effectiveness and challenges of multiple recruitment methods, described as proactive, reactive, and combination methods, among adult African American smokers (N = 527) from economically disadvantaged urban communities enrolled to test progressively reduced nicotine content investigational cigarettes. The study evaluated success using descriptive statistics to measure the volume of phone calls and percentage of eligible participants per method. Reactive and combination strategies effectively prompted participants to call about the study. Combination methods yielded the highest eligibility rates. Findings demonstrate the unique recruitment successes within this population across a range of recruitment methods and may inform improved methods to recruit and engage African Americans in clinical trials.