Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review

Effectiveness of implementation strategies for venous leg ulcer guidelines: A systematic review

BACKGROUND

The aim of clinical practice guidelines (CPGs) is to improve patient care; however inconsistencies between recommended practice and what actually happens in clinical practice continues. Venous Leg Ulcers (VLUs) have a significant negative impact on patients' quality of life and it is acknowledged that managing people with venous leg ulcers is protracted and costly. The aim of this review is to identify the most effective strategies to implement clinical practice guidelines for the management of VLUs by health care professionals in the hospital, outpatient, home and community setting.

METHODS

A systematic review guided by methods from the Cochrane Effective Practice and Organisation of Care (EPOC) group was undertaken to identify implementation strategies for VLU clinical practice guidelines. Eligible studies were identified via systematic electronic searches of Medline, Embase, CINHAL and the Cochrane Library.

RESULTS

We identified 142 potential studies of which one randomised controlled trial met the inclusion criteria. Following an analysis of the included study, it is not possible to recommend one implementation strategy over another when implementing practice guidelines for people with VLUs.

CONCLUSION

We identified a limited evidence base for the effectiveness of implementation strategies for VLU CPGs. No one implementation strategy is better than another to facilitate VLU CPG implementation by health care professionals in hospital, outpatient, home or community settings.

Adherence to guidelines for androgen deprivation therapy after radical prostatectomy: Swedish population-based study

Background: Androgen deprivation therapy (ADT) is a non-curative but essential treatment of prostate cancer with severe side effects. Therefore, both over- and underuse should be avoided. We investigated adherence to guidelines for ADT following radical prostatectomy through Swedish population-based data.Material and methods: We used the database Uppsala/Örebro PSA cohort (UPSAC) to study men with localised or locally advanced prostate cancer at diagnosis (clinical stage T1-T3, N0-NX, M0-MX, and prostate-specific antigen (PSA) <50 ng/ml) who underwent radical prostatectomy 1997-2012. 114 men were treated with ADT and selected as cases; 1140 men with no ADT at the index date were selected as controls within 4-year strata of year of radical prostatectomy. All men with a biochemical recurrence and a PSA doubling time <12 months and/or a Gleason score of 8-10 were considered to have an indication for ADT according to the European Association of Urology (EAU) guidelines.Results: No indication for ADT was found in 37% of the cases. Among these, 88% had clinical stage T1-2 at diagnosis, 57% had a biopsy Gleason score 2-6, 98% had an expected remaining lifetime over 10 years, 12% received castration, and 88% received antiandrogen monotherapy. 2% of controls were found to have an indication for ADT, and 96% of these had an expected remaining lifetime over 10 years.Conclusion: Our results indicate that overtreatment with ADT after radical prostatectomy is common, whereas undertreatment is unusual. Interventions to improve adherence to guidelines are needed to avoid unnecessary side-effects and long treatment durations with ADT.

Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines

Background Post-traumatic seizure (PTS) is a major complication of traumatic brain injury (TBI). However, there has been controversy in the literature regarding whether anticonvulsants should be used prophylactically to prevent it, and there is significant variability in practice. The objective of this study is to describe seizure prophylaxis practices after moderate to severe TBI and to determine whether the use of seizure prophylaxis increased following the recommendations of the Quebec Institut National d'Excellence en Santé et Services Sociaux and the Ontario Neurotrauma Foundation (INESSS-ONF) guidelines. This study will also compare the characteristics of patients who receive the recommended prophylaxis and those who do not. Methods All adult patients admitted to a level-1 trauma centre for moderate to severe TBI were eligible for this study (n = 96). Medical records including patient age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, and occurrence of PTS were reviewed in a retrospective manner regarding the administration of recommended seizure prophylaxis. Results The proportion of patients receiving the recommended seizure prophylaxis was 8%. There was no significant increase after the release of the INESSS-ONF guidelines (p: 0.38). There were no significant differences in demographics, injury characteristics, or rates of early PTS between patients receiving the recommended prophylaxis and those not receiving it (p: >0.05). Conclusion The results indicate that the use of the recommended seizure prophylaxis after moderate to severe TBI is low and that the release of the INESSS-ONF guidelines did not increase its use. Patient and injury factors do not appear to influence the use of seizure prophylaxis. These results highlight variability in seizure prophylaxis practices and the importance of understanding local practice patterns. Implementation strategies should be identified to increase adherence to the recommendations and improve patient care.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

National clinical guidelines in municipality-based rehabilitation: A cross-sectional survey of knowledge, use, and implementation

Background: Despite increasing research within physiotherapy, consistent implementation of evidence-based guidelines in everyday physiotherapy practice can present a challenge.Objective: To examine the knowledge, use, and implementation of National Clinical Guidelines (NCG) for knee arthrosis and meniscus pathology in municipality-based rehabilitation in Denmark.Methods: A cross-sectional survey using a web-based questionnaire developed for the present study. Respondents included rehabilitation unit managers, staff in charge of professional development and physiotherapists from municipality-based rehabilitation units in one of the Denmark's five regions.Results: The questionnaire was completed by 61 respondents (75.3%). The responses indicated significantly better knowledge of the NCG for knee arthrosis than of the NCG for meniscus pathology (p = .017). Eighty-two percent (n = 50) replied that their unit had developed local guidelines for knee arthrosis; 74% (n = 45) for meniscus pathology. A total of 72% (n = 44) stated that relevant parts of the knee arthrosis NCG were integrated in local guidelines, whereas only 49% (n = 30) said the same for the meniscus pathology NCG. Respondents replied that implementation depends on factors such as time (46%, n = 28), knowledge (31%, n = 19), and the perceived relevance of the NCG (33%, n = 20) as well as support from local rehabilitation unit managers (23%, n = 14).Conclusion: Differences in the knowledge, use, and implementation of two NCGs among rehabilitation unit managers, staff in charge of professional development, and physiotherapists in municipality-based rehabilitation were identified. It seems that NCGs do not necessarily translate directly into local guidelines.

Clinicians' attitudes to oncology clinical practice guidelines and the barriers and facilitators to adherence: a mixed methods study protocol

INTRODUCTION

Clinical practice guidelines (CPGs) are designed to reduce inappropriate clinical variation and improve the quality of care. Barriers to CPGs include a lack of awareness of CPGs, access to them, time pressures and concerns regarding the evidence underpinning CPG development, implementation and dissemination. The objectives of this study are to assess clinicians' attitudes to CPGs for cancer treatment and the perceived barriers to and facilitators of CPG adherence in order to inform the implementation of cancer treatment CPGs.

METHODS AND ANALYSIS

A mixed methods study will be conducted using a three-phase, sequential design, with each phase informing the next. In phase 1, a qualitative study using recorded interviews will investigate clinicians' attitudes to CPGs for cancer treatment and perceptions of barriers and facilitators to CPG adherence (n=30); interview transcripts will be analysed thematically. In phase 2, a survey will quantify the frequency of attitudes, barriers and facilitators identified in phase 1, in a broader clinical sample (n=200). In phase 3, a workshop forum will be held to facilitate discussions examining the implications of phase 1 and 2 findings for cancer CPG implementation strategies (n=40) leading to recommendations for improvements to practice. The workshop discussion will be recorded, and the transcript will be analysed thematically.

ETHICS AND DISSEMINATION

This study has received ethics approval in New South Wales, Australia (2019/ETH11722, #52019568810127). Study findings will be published in peer-reviewed journals and will form part of a doctoral thesis and be presented at national and international conferences.

Nutrition Support Teams: A Systematic Review

BACKGROUND

The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

METHODS

Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

RESULTS

The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

CONCLUSION

Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.

How guideline can shape clinical practice globally: the diagnosis and rationale for action against cow's milk allergy experience

PURPOSE OF REVIEW

Allergic diseases are increasing worldwide and are considered an important public health problem causing severe and even life-threatening reactions. The creation of guidelines aims to help clinicians improving the quality of diagnosis and management of such diseases. Clinical practice guidelines alone are not sufficient and there is a need for implementation strategies for their introduction into daily practice. We report here the main international allergy guidelines with a more focused look on the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines and their effect on clinical practice.

RECENT FINDINGS

DRACMA guidelines have clearly modified the approach to cow's milk allergy (CMA) from its diagnosis to treatment tailoring the choices for each patient. Although they strongly recommend oral food challenge for diagnosing CMA, they also indicate that it may not be necessary in many cases with the introduction of the pretest probability of CMA. Studies on the implementation of DRACMA guidelines show how they influenced the formula market, making appropriate treatments more affordable.

SUMMARY

DRACMA reconciled international differences in the diagnosis and management of CMA. They introduced the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology in the field of food allergy and highlighted the importance for meta-analyses to be able to adapt recommendations to the local context.

Views of health care professionals and policy-makers on the use of surveillance data to combat antimicrobial resistance

BACKGROUND

Providing healthcare professionals with health surveillance data aims to support professional and organisational behaviour change. The UK Five Year Antimicrobial Resistance (AMR) Strategy 2013 to 2018 identified better access to and use of surveillance data as a key component. Our aim was to determine the extent to which data on antimicrobial use and resistance met the perceived needs of health care professionals and policy-makers at national, regional and local levels, and how provision could be improved.

METHODS

We conducted 41 semi-structured interviews with national policy makers in the four Devolved Administrations and 71 interviews with health care professionals in six locations across the United Kingdom selected to achieve maximum variation in terms of population and health system characteristics. Transcripts were analysed thematically using a mix of a priori reasoning guided by the main topics in the interview guide together with themes emerging inductively from the data. Views were considered at three levels - primary care, secondary care and national - and in terms of availability of data, current uses, benefits, gaps and potential improvements.

RESULTS

Respondents described a range of uses for prescribing and resistance data. The principal gaps identified were prescribing in private practice, internet prescribing and secondary care (where some hospitals did not have electronic prescribing systems). Some respondents under-estimated the range of data available. There was a perception that the responsibility for collecting and analysing data often rests with a few individuals who may lack sufficient time and appropriate skills.

CONCLUSIONS

There is a need to raise awareness of data availability and the potential value of these data, and to ensure that data systems are more accessible. Any skills gap at local level in how to process and use data needs to be addressed. This requires an identification of the best methods to improve support and education relating to AMR data systems.

Factors Influencing Uptake of Changes to Clinical Preventive Guidelines

BACKGROUND

Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines.

METHODS

Semistructured interviews conducted in 2018 with a diverse sample of clinicians and practice leaders sought to understand patient, clinician, practice, health system, environment, and guideline factors of influence. An immersion-crystallization approach was used to identify emergent themes.

RESULTS

Interviewees expressed motivation to adhere to guidelines but also valued sharing decisions with patients. Personal biases and fears affected both clinician and patient guideline adoption. Practices facilitated implementation through workflow optimization and encouraging a culture of evidence-based practice while a key health system function was to maintain electronic health record alerts. More traditional environmental factors, such as insurance coverage or transportation, were less of a barrier to guideline adoption and implementation than the influence of media and specialists. Various specific guideline characteristics also affected ease of adoption and implementation. Different settings expressed greater health system, practice, or clinician-centric approaches to guideline implementation.

CONCLUSIONS

Guideline uptake is influenced by a complex interplay of multiple levels of factors including the patient, clinician, practice, health system, environment, and guideline levels. Comprehensively understanding all levels of influence for each specific clinical setting may help to determine the optimal intervention(s) for improving uptake of evidence-based guidelines.

Identifying the most effective essential medicines policies for quality use of medicines: A replicability study using three World Health Organisation data-sets

Background

Poor quality use of medicines (QUM) has adverse outcomes. Governments’ implementation of essential medicines (EM) policies is often suboptimal and there is limited information on which policies are most effective.

Methods

We analysed data on policy implementation from World Health Organisation (WHO) surveys in 2007 and 2011, and QUM data from surveys during 2006–2012 in developing and transitional countries. We compared QUM scores in countries that did or did not implement specific policies and regressed QUM composite scores on the numbers of policies implemented. We compared the ranking of policies in this and two previous studies, one from the same WHO databases (2003–2007) the other from data obtained during country visits in South-East Asia (2010–2015). The rankings of a common set of 17 policies were correlated and we identified those that were consistently highly ranked.

Findings

Fifty-three countries had data on both QUM and policy implementation. Forty policies were associated with effect sizes ranging from +13% to -5%. There was positive correlation between the composite QUM indicator and the number of policies reported implemented: (r) = 0.437 (95% CI 0.188 to 0.632). Comparison of policy rankings between the present and previous studies showed positive correlation with the WHO 2003–7 study: Spearman’s rank correlation coefficient 0.498 (95% CI 0.022 to 0.789). Across the three studies, five policies were in the top five ranked positions 11 out of a possible 15 times: drugs available free at the point of care; a government QUM unit; undergraduate training of prescribers in standard treatment guidelines, antibiotics not available without prescription and generic substitution in the public sector.

Interpretation

Certain EM policies are associated with better QUM and impact increases with co-implementation. Analysis across three datasets provides a policy short-list as a minimum investment by countries trying to improve QUM and reduce antimicrobial drug misuse.

Clinical Decision Making at the Bedside

The complexity and rapidly changing environment of health care places significant pressure on nurses. How nurses make decisions within this environment has been an area of inquiry in the literature. Clinical decision making is the application of distinct thinking patterns and analysis of data at hand used to make judgements about patient care. Models of clinical decision making provide a foundation for understanding how nurses make decisions. Key factors associated with clinical decision making include experience, intuition, use of information and sources, and environment. Further work is needed to increase understanding of the processes by which nurses make clinical decisions.

A unique framework for the Persian clinical guidelines: addressing an evidence-based CDSS development need

BACKGROUND AND AIM

One of the prerequisites to develop Computerised Decision Support Systems is Clinical Practice Guidelines (CPGs) which provide a systematic aid to make complex medical decisions. In order to provide an automated CPG, it is needed to have a unique structure for the CPGs. This study aims to propose a unique framework for the Persian guidelines.

MATERIALS AND METHODS

20 Persian CPGs were selected and divided into the creation and validation sets (n=10 for each). The first group was studied independently and their headings were listed; wherever possible, the headings were merged into a new heading that was applicable to all the guidelines. The developed framework was validated by the second group of the guidelines.

RESULTS

Studied guidelines had a very heterogeneous structure. The number of original headings was 249; they were reduced to 14 main headings with 16 subheadings in a unique developed framework. The framework is able to represent and cover 100% of the guidelines.

CONCLUSION

The heterogeneity of guidelines was high as they were not developed based on the unique framework. The proposed framework provides a layout for designing the CPGs with a homogeneous structure. Guideline developers can use this framework to develop structured CPGs. This will facilitate the integration of the guidelines into electronic medical records as well as clinical decision support systems.

Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study

Background

Community acquired pneumonia (CAP) remains a significant cause of morbidity and in-hospital mortality, and readmission rates are rising for older persons (> 65 years). Optimized treatment and nursing care will benefit patients and the health economy. Hence, there is a need to describe gaps between current clinical practice and recommendations in evidence-based guidelines for diagnostic procedures, medical treatment and nursing interventions for older patients with CAP.

Methods

Structured observations, individual ad hoc interviews and audits of patient records were carried out in an emergency department and three medical units. Data were analysed by manifest content analysis and descriptive statistics.

Results

Thirty patients (median age 74 years) admitted with CAP and 86 physicians, nurses, physiotherapists were included. The median length of stay (LOS) was 6.5 days, in-hospital mortality was10 and 40.7% were readmitted within one month. The severity assessment tool (CURB-65) was used in 16.7% of the patients, correct antibiotic treatment prescribed for 13.3% and chest radiography (≤6 weeks post-discharge) prescribed for 22.2%. Fluid therapy, nutrition support and mobilisation plans were found to be developed sporadically, and interventions to be performed unsystematically and sparingly. Positive Expiratory Pressure therapy and oral care were the nursing interventions with lowest adherence, ranging from 18.2 to 55.6%.

Conclusions

Adherence to recommendations was low for several central treatment and nursing care interventions for patients with CAP with possible consequences for patients and the use of resources. Thus, there is an urgent need to identify and remove barriers to adherence to recommendations in the neglected areas in view of the potential to improve patient outcomes.

Improving adherence to cardiovascular guidelines: realistic transition from paper to patient

Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.

Guidelines for Long-Term Follow-Up after Childhood Cancer: Practical Implications for the Daily Work

BACKGROUND

Many childhood cancer survivors develop treatment-associated late effects emerging years or even decades after the end of treatment. Evidence-based guidelines recommend risk-adapted screening, facilitating early diagnosis and management of these sequelae. Long-term follow-up (LTFU) in specialized late effects clinics is devised to implement screening recommendations in the care of childhood cancer survivors.

OBJECTIVES

To create a practical LTFU tool for the daily practice.

METHODS

Current guidelines and screening recommendations concerning LTFU in adult survivors of childhood cancer were reviewed and a comprehensive LTFU approach was developed.

RESULTS

A risk stratification model assigning patients to three risk groups with different screening recommendations and frequencies is presented based on current LTFU guidelines. Furthermore, a model of LTFU in a clinical multidisciplinary team is proposed.

CONCLUSIONS

Although late morbidity and mortality in childhood cancer survivors have been attenuated in the last decade by reducing treatment toxicities, a high proportion of long-term survivors already is or will still be affected by treatment-associated chronic health conditions. With the knowledge of late effects and their occurrence as a consequence of specific treatment modalities, practical LTFU recommendations are essential to achieve standardized and structured LTFU care.

Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices?

BACKGROUND/OBJECTIVES

Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes.

METHODS

This retrospective cohort study of patients admitted to ten adult, medical-surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines.

RESULTS

20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6-100%) and by type of VTE prophylaxis recommended (p = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline (p = 0.005).

CONCLUSIONS

Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.

Barriers and enablers in the implementation of a standardised process for nutrition care: findings from a multinational survey of dietetic professionals in 10 countries

BACKGROUND

To explore the barriers and enablers experienced by nutrition and dietetic professionals in the implementation of the standardised Nutrition Care Process (NCP) across 10 different countries. NCP related beliefs, motivations and values were investigated and compared.

METHODS

A validated online survey was disseminated to nutrition and dietetics professionals in 10 countries in the local language during 2017. Cross-sectional associations and differences between countries were explored for level of implementation, barriers/enablers and attitudes/motivation among the respondents.

RESULTS

Higher NCP implementation was associated with greater occurrence of enabling aspects, as well as fewer occurrences of barriers. The most common enabler was 'recommendation by the national dietetic association' (69%) and the most common barrier was 'lack of time' (39%). A longer experience of NCP use was associated with a more positive attitude towards all NCP aspects. Differences between countries were identified, regarding both the occurrence of barriers/enablers and attitudes/motivations.

CONCLUSIONS

Implementation efforts need to be tailored to country-specific contexts when implementing a new standard of care framework among nutrition and dietetic professionals. Additional research is needed to further assess the management and workplace strategies to support the development of nutrition and dietetics professionals in multidisciplinary healthcare organisations.

Neonatal resuscitation guideline adherence: simulation study and framework for improvement

We wanted to assess newborn life support (NLS) knowledge and guideline adherence, and provide strategies to improve (neonatal) resuscitation guideline adherence. Pediatricians completed 17 multiple-choice questions (MCQ). They performed a simulated NLS scenario, using a high-fidelity manikin. The literature was systematically searched for publications regarding guideline adherence. Forty-six pediatricians participated: 45 completed the MCQ, 34 performed the scenario. Seventy-one percent (median, IQR 56-82) of the MCQ were answered correctly. Fifty-six percent performed inflation breaths ≤ 60 s, 24% delivered inflation breaths of 2-3 s, and 85% used adequate inspiratory pressures. Airway patency was ensured 83% (IQR 76-92) of the time. Median events/min, compression rate, and percentage of effective compressions were 138/min (IQR 130-145), 120/min (IQR 114-120), and 38% (IQR 24-48), respectively. Other adherence percentages were temperature management 50%, auscultation of initial heart rate 100%, pulse oximeter use 94%, oxygen increase 74%, and correct epinephrine dose 82%. Ten publications were identified and used for our framework. The framework may inspire clinicians, educators, researchers, and guideline developers in their attempt to improve resuscitation guideline adherence. It contains many feasible strategies to enhance professionals' knowledge, skills, self-efficacy, and team performance, as well as recommendations regarding equipment, environment, and guideline development/dissemination.Conclusion: NLS guideline adherence among pediatricians needs improvement. Our framework is meant to promote resuscitation guideline adherence. What is Known: • Inadequate newborn life support (NLS) may contribute to (long-term) pulmonary and cerebral damage. • Video-based assessment of neonatal resuscitations has shown that deviations from the NLS guideline occur frequently; this assessment method has its audiovisual shortcomings. What is New: • The resuscitation quality metrics provided by our high-fidelity manikin suggest that the adherence of Dutch general pediatricians to the NLS guideline is suboptimal. • We constructed a comprehensive framework, containing multiple strategies to improve (neonatal) resuscitation guideline adherence.

Why Do Clinical Practice Guidelines Get Stuck during Implementation and What Can Be Done: A Case Study in Pediatric Rehabilitation

Aims: The purpose of this study was to obtain the perspectives of occupational and physical therapists working in pediatric rehabilitation about the factors that influence implementation of clinical practice guidelines (CPG) using the case of constraint induced movement therapy (CIMT). We aimed to identify factors that hinder implementation of CPGs and strategies for overcoming barriers when widespread implementation is stalled.Methods: Qualitative case study methodology was bounded within the parameters of CIMT implementation in pediatric rehabilitation in one jurisdiction. Twenty-one occupational and physical therapists participated in one of three focus groups. Data were analyzed using an inductive qualitative approach.Results: Participants viewed CPGs as useful, and emphasized the importance of consistency between guidelines and relevance to practice context. Therapists considered the "art and science" in clinical decision-making. Barriers and facilitators to CPG implementation were identified at the client, clinician, intervention location and systemic level. Potential solutions to help "unstick" guideline implementation were consistent with theories of collective knowledge exchange and mindlines.Conclusion: The presence of CPGs does not ensure evidence uptake; understanding of local barriers is required. This case study highlights the value of a collective knowledge exchange approach and attention to the social structures of knowledge development and evidence use.

Implementation of the protocol of nursing care in trauma in aeromedical service

ABSTRACT Objective: To analyze the implementation of a nursing care protocol for trauma patients before, during and after the flight. Method: A cross-sectional quantitative study carried out in an aeromedical service, using a checklist with 106 care: 79 before flight, 25 during, and 2 after flight. 97 patients were included in the study. Results: Most care (n = 59; 55.7%) was implemented, totaling 4,435, 1,480 and 192 cares performed before, during and after the flight, respectively. They stood out as unrealized care: protect ears with ear muffler (n = 55) and avoid leaving the pulse oximeter exposed to the sun’s rays (n = 22). The main reason for the non-performance was lack of appeal (n = 94). Conclusion: Although most protocol care has been implemented, unrealized care compromises the quality of care, which requires the management of the service to provide more incentive to nurses and adequate resources for its implementation.

Follow-Up Treatment After Inpatient Therapy of Patients With Unipolar Depression-Compliance With the Guidelines?

OBJECTIVE

To date, there is only a limited number of studies evaluating the implementation and effects of treatment guidelines. Therefore, this study aimed to determine how many patients diagnosed with a major depression were treated in compliance with the German treatment guideline after hospital treatment, and whether a deviation from the guideline resulted in a less favorable development.

METHODS

Five hundred two patients, which originally participated in the INDDEP-study, were included. Data were collected at admission and discharge from eight different psychosomatic (psychotherapeutic) hospitals in Germany as well as 3 months and 1 year after hospital treatment. Data on depressive symptomatology were assessed by QIDS-C (clinical interviews). By phone interviews, the clinical course and the outpatient treatments were assessed. Statistical analyses compared patients who were treated in compliance with the German treatment guideline with those who were not.

RESULTS

Seventy-nine point one percent of the outpatient treatments complied with the treatment guideline. Eleven point eight percent of the patients were treated with medication only, 60.2% with psychotherapy only, and 28.0% with a combination. There was no difference in the clinical outcome (depression) with regard to guideline compliance. Cases in which deviation from the guideline occurred (20.9%) were younger and had a less severe depressive symptomatology at admission and after hospital treatment.

CONCLUSION

After treatment in a psychosomatic hospital or day hospital, the majority of patients with a depressive disorder received adjacent treatment in accordance with the German guideline and with a clear focus on psychotherapy. Deviations from the guideline did not result in a less favorable course of the illness.

CLINICAL TRIAL REGISTRATION

ISRCTN20317064, retrospectively registered 31.07.2012.

National Cervical Screening Program renewal in Australia: survey of clinician views and attitudes

From 1 December 2017, the National Cervical Screening Program was renewed in Australia, with updated national cervical screening guidelines released. This study was performed to determine clinicians’ familiarity with the updated guidelines and explore their views and attitudes towards the renewed program. Clinicians providing cervical screening in New South Wales, Australia, were invited to complete an online survey in 2018. Of the 241 clinicians who responded, 91.5% supported the change to 5-yearly human papillomavirus screening from the age of 25 years. However, nearly 13% indicated they did not know where to access the renewed guidelines and 37% had never or rarely accessed them. Open-ended responses highlighted clinicians’ concerns about missed cancers and missed opportunities for health checks. Those raising these concerns accessed the guidelines less frequently. The findings highlight important areas for additional education and support for clinicians in translating guidelines into practice to ensure successful delivery of the renewed program.

Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period

PURPOSE

To explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units.

DESIGN

A qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews.

METHODS

Data collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used.

FINDINGS

The results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment.

CONCLUSIONS

Several barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.

The effectiveness of guideline implementation strategies in the dental setting: a systematic review

BACKGROUND

Guideline implementation has been an ongoing challenge in the dental practice setting. Despite this, there are no reviews summarising the existing evidence regarding effective guideline implementation strategies in this setting. In order to address this, this systematic review examines the effectiveness of guideline implementation strategies in the dental practice setting.

METHODS

A systematic search was undertaken according to the PRISMA statement across nine electronic databases, targeting randomised controlled trials and quasi-experimental studies which evaluated the effectiveness of guideline implementation strategies in improving guideline adherence in the dental setting. All records were independently examined for relevance and appraised for study quality by two authors, with consensus achieved by a third author. Data were extracted from included studies using a standardised data extraction pro forma.

RESULTS

A total of 15 records were eligible for inclusion in this review, which focused on the effects of audit and feedback, reminders, education, patient-mediated interventions, pay for performance and multifaceted interventions. Although there were some conflicting evidence, studies within each category of implementation strategy indicated a positive effect on guideline adherence.

CONCLUSIONS

This study has identified education, reminders and multifaceted interventions as effective implementation strategies for the dental practice setting. Although this is similar to research findings from other health sectors, there is some evidence to suggest patient-mediated interventions may be less effective and pay for performance may be more effective in the dental setting. These findings can inform policy makers, professional associations, colleges and organisations in the future adoption of clinical guidelines in the dental practice setting.

TRIAL REGISTRATION

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration ID CRD42018093023.

The role of real-world data in the development of treatment guidelines: a case study on guideline developers' opinions about using observational data on antibiotic prescribing in primary care

Background

Antimicrobial resistance (AMR) is a prominent threat to public health. Although many guidelines have been developed over the years to tackle this issue, their impact on health care practice varies. Guidelines are often based on evidence from clinical trials, but these have limitations, particularly in the breadth and generalisability of the evidence and evaluation of the guidelines’ uptake. The aim of this study was to investigate how national and local guidelines for managing common infections are developed and explore guideline committee members’ opinions about using real-world observational evidence in the guideline development process.

Methods

Six semi-structured interviews were completed with participants who had contributed to the development or adjustment of national or local guidelines on antimicrobial prescribing over the past 5 years (from the English National Institute for Health and Care Excellence (NICE)). Interviews were audio recorded and transcribed verbatim. Data was analysed thematically. This also included review of policy documents including guidelines, reports and minutes of guideline development group meetings that were available to the public.

Results

Three key themes emerged through our analysis: perception versus actual guideline development process, using other types of evidence in the guideline development process, and guidelines are not enough to change antibiotic prescribing behaviour. In addition, our study was able to provide some insight between the documented and actual guideline development process within NICE, as well as how local guidelines are developed, including differences in types of evidence used.

Conclusions

This case study indicates that there is the potential for a wider range of evidence to be included as part of the guideline development process at both the national and local levels. There was a general agreement that the inclusion of observational data would be appropriate in enhancing the guideline development process, as well providing a potential solution for monitoring guideline use in clinical practice, and improving the implementation of treatment guidelines in primary care.

Interventions to Improve Metabolic Risk Screening Among Adult Patients Taking Antipsychotic Medication: A Systematic Review

OBJECTIVE

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.

METHODS

Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.

RESULTS

The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).

CONCLUSIONS

This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

Plaque control and reduction of gingivitis: The evidence for dentifrices

This paper focuses on plaque control and the management of gingivitis in adults and summarizes the evidence of commercially available dentifrices as gathered from existing systematic reviews. Three internet sources were used to search for appropriate papers (up to and including February 2017). The search strategy was designed to include any systematic review published on dentifrices that also included an evaluation of plaque and gingivitis scores. Characteristics of the individual reviews, such as methodological aspects, quantitative data and conclusions, were extracted. The potential risk of bias was estimated and the acquired evidence was graded. Independent screening of 205 unique reviews resulted in 10 published and eligible systematic reviews. One publication evaluated the mechanical contribution of dentifrice to plaque removal. Eight papers were identified that evaluated the efficacy of a proposed single active ingredients, of which two reviewed more than one potentially active ingredient. One study compared two active ingredients. This meta‐review appraised the current state of evidence and found that toothbrushing with a standard fluoride dentifrice does not provide an added effect for the mechanical removal of dental plaque. Evidence suggests that compared with a standard dentifrice, those containing triclosan or stannous fluoride have benefits with respect to gingival health and control of dental plaque.

Adoption of immunotherapy in the community for patients diagnosed with metastatic melanoma

BACKGROUND

The introduction of immune checkpoint inhibitors has led to a survival benefit in patients with advanced melanoma; however data on the adoption of immunotherapy in the community are scarce.

METHODS

Using the National Cancer Database, we identified 4725 patients aged ≥20 diagnosed with metastatic melanoma in the United States between 2011 and 2015. Multinomial regression was used to identify factors associated with the receipt of treatment at a low vs. high immunotherapy prescribing hospital, defined as the bottom and top quintile of hospitals according to their proportion of treating metastatic melanoma patients with immunotherapy.

RESULTS

We identified 246 unique hospitals treating patients with metastatic melanoma. Between 2011 and 2015, the proportion of hospitals treating at least 20% of melanoma patients with immunotherapy within 90 days of diagnosis increased from 14.5 to 37.7%. The mean proportion of patients receiving immunotherapy was 7.8% (95% Confidence Interval [CI] 7.47-8.08) and 50.9% (95%-CI 47.6-54.3) in low and high prescribing hospitals, respectively. Predictors of receiving care in a low prescribing hospital included underinsurance (no insurance: relative risk ratio [RRR] 2.44, 95%-CI 1.28-4.67, p = 0.007; Medicaid: RRR 2.10, 95%-CI 1.12-3.92, p = 0.020), care in urban areas (RRR 2.58, 95%-CI 1.34-4.96, p = 0.005) and care at non-academic facilities (RRR 5.18, 95%CI 1.69-15.88, p = 0.004).

CONCLUSION

While the use of immunotherapy for metastatic melanoma has increased over time, adoption varies widely across hospitals. Underinsured patients were more likely to receive treatment at low immunotherapy prescribing hospitals. The variation suggests inequity in access to these potentially life-saving drugs.

Teleneurology clinics for polyneuropathy: a pilot study

Introduction

Polyneuropathy (PN) is a common condition with significant morbidity. We developed tele-polyneuropathy (tele-PN) clinics to improve access to neurology and increase guideline-concordant PN care. This article describes the mixed-methods evaluation of pilot tele-PN clinics at three community sites within the Greater Los Angeles VA Healthcare System.

Methods

For the first 25 patients (48 scheduled visits), we recorded the duration of the tele-PN visit and exam; the performance on three guideline-concordant care indicators (PN screening labs, opiate reduction, physical therapy for falls); and patient-satisfaction scores. We elicited comments about the tele-PN clinic from patients and the clinical team. We combined descriptive statistics with qualitative themes to determine the feasibility and acceptability of the tele-PN clinics.

Results

The average tele-PN encounter and exam times were 28.5 and 9.1 min, respectively. PN screening lab completion increased from 80 to 100%. Opiate freedom improved from 68 to 88%. Physical therapy for patients with recent falls increased from 58 to 100%. The tele-PN clinic was preferred for follow-up over in-person clinics in 86% of cases. Convenience was paramount to the clinic’s success, saving an average of 231 min per patient in round-trip travel. The medical team’s caring and collaborative spirit received high praise. While the clinic’s efficiency was equal or superior to in-person care, the limited treatment options for PN and the small clinical exam space are areas for improvement.

Conclusion

In this pilot, we were able to efficiently see and examine patients remotely, promote guideline-concordant PN care, and provide a high-satisfaction encounter.

Community-based maternal and child health project on 4+ antenatal care in the Democratic Republic of Congo: a difference-in-differences analysis

Background

Despite efforts to achieve the Millennium Development Goals, the maternal mortality ratio in the Democratic Republic of Congo was 693 per 100,000 in 2015—the 6th highest in the world and higher than the average (547 per 100,000) in sub-Saharan Africa. Antenatal care (ANC) service is a cost-effective intervention for reducing the maternal mortality ratio in low-income countries. This study aimed to identify the intervention effect of the maternal and child health care (MCH) project on the use of four or more (4⁺) ANC services.

Methods

The MCH project was implemented using the three delays model in Kenge city by the Ministry of Public Health (MoPH) of the DRC with technical assistance from Korea International Cooperation Agency (KOICA) and the Yonsei Global Health Center from 2014 to 2017. Furthermore, Boko city was selected as the control group. A baseline and an endline survey were conducted in order to evaluate the effectiveness of this project. We interviewed 602 and 719 participants in Kenge, and 150 and 614 participants in Boko in the baseline and endline surveys, respectively. We interviewed married reproductive-aged women (19–45 years old) in both cities annually. The study instruments were developed based on the UNICEF Multiple Indicator Cluster Surveys. This study used the homogeneity test and the binary logistic regression difference-in-differences method of analysis.

Results

The odds of reproductive-aged women’s 4+ ANC service utilization at the intervention site increased 2.280 times from the baseline (OR: 2.280, 95% CI: 1.332–3.902, p = .003) as compared to the control site.

Conclusions

This study showed that the KOICA MCH project effectively increased the 4⁺ ANC utilization by reproductive-aged women in Kenge. As the 4+ ANC services are expected to reduce maternal deaths, this project might have contributed to reducing maternal mortality in Kenge. In the future, we expect these findings to inform MCH policies of the MoPH in the DRC.

Use of social media for communicating about critical care topics: A Norwegian cross-sectional survey

BACKGROUND

Social media (SoMe) might be an alternative platform for communicating critical care topics to implement evidence-based practice in the intensive care unit (ICU). This survey aims to describe ICU nurses' and physicians' use of SoMe in general, and their perception of using closed Facebook-groups for receiving content on critical care topics.

METHODS

A cross-sectional, web-based, anonymous survey was distributed to ICU physicians and nurses in four ICUs in autumn 2017 via an email-campaign. Descriptive statistics with rates, percentages and median numeric rating scale (NRS) scores, interquartile ranges are presented.

RESULTS

The response-rate was 64% (253/ 394) including 210 nurses and 43 physicians. Overall, 93% had a SoMe-profile, and 77% had a profile on more than one network site. Facebook was the most used social network site, with 87% having a profile. Totally, 68% were daily users, but more nurses used Facebook daily vs physicians (81% vs 60%, respectively, P = 0.006). Nurses were also more positive toward being members of closed Facebook-groups aimed to exchange content on critical care topics (median NRS 9 (6-10) vs 6 (3-9), respectively, P = 0.014).

CONCLUSION

The majority of ICU nurses and physicians were active SoMe users, mainly for personal purposes, and Facebook was the most popular SoMe. Nurses used Facebook daily more frequent and were more positive toward content on critical care topics on Facebook than physicians. These findings might be relevant to customize future communication about critical care topics via SoMe.

Antibiotics prescription and guidelines adherence in elderly: impact of the comorbidities

Background

Although the interest of antibiotics is well known, antibiotics prescription is associated with side effect, especially in patients with multiples comorbidities. One way to reduce the incidence of side effects is to respect antibiotics prescriptions guidelines. Our objective was to investigated the factors associated with guidelines adherence in elderly patients with multiples comorbidities.

Methods

From October 2015 to December 2016, antibiotics prescription and guidelines adherence were analyzed in two post-acute care and rehabilitation services of a 2600-bed, university-affiliated center.

Results

One hundred and twenty-eight patients were included, fifty-nine (46%) patients had antibiotics prescription according to guidelines. In Multivariable logistic regression analysis, prescription of 2 antibiotics or more (OR = 0.168, 95% IC = 0.037–0.758, p < 0.05), 85 years of age and more (OR = 0.375, 95% IC = 0.151–0.931, p < 0.05) and the Charlson comorbidity index score (OR = 0.750, 95% IC = 0.572–0.984, p < 0.05) were negatively associated with antibiotics prescriptions according to guidelines.

Conclusions

High comorbidity in the elderly was negatively associated with the guidelines adherence of antibiotiсs prescriptions. These criteria should be considered to optimize antibiotics prescriptions in elderly patients.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1265-1) contains supplementary material, which is available to authorized users.

Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence

Background

Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice.

Methods

The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases.

Result

All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity.

Conclusions

Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.

Person-centered dementia care in acute hospital wards-The influence of staff knowledge and attitudes

Person-centered dementia care practices in acute hospital wards are suboptimal and not commonly measured. Although previous research has indicated that the work environment of staff influences their perceptions of person-centeredness, few studies have examined how their personal attributes, such as their level of dementia knowledge and attitudes, influence their person-centered dementia care practices. A questionnaire was distributed to test the relationship between staff perceptions of person-centered dementia care and their dementia knowledge and attitudes in general medical wards. The results showed that staff with better dementia knowledge were significantly more critical about the extent they were using evidence-based guidelines and external expertise. Staff with better attitudes perceived themselves as using more individualized care practices. The findings demonstrate that to enhance person-centered dementia care in acute hospitals, staff training programs should develop both their intellectual and interpersonal skills to improve their knowledge and attitudes.

The Dutch chaos case: A scoping review of knowledge and decision support tools available to clinicians in the Netherlands

BACKGROUND

To keep clinicians up-to-date with the latest evidence, clinical practice and patient preferences, more and more knowledge tools - aiming to synthesise knowledge and support (shared) decision-making - are being developed. Unfortunately, it seems that in the Netherlands, and possibly elsewhere, the amount of different knowledge tool types makes it difficult to see the forest through the trees.

METHODS

A scoping review, exploring types of knowledge tools available to Dutch clinicians (and patients) and how these tools are described. The search terms were collected from thesauri and textbooks, and used to search the websites and documents of selected national tool developing organisations.

RESULTS

The review yielded 126 tool types. We included 67 different tool types, such as guidelines, protocols, standards and clinical pathways. Half of those tool types were aimed at clinicians, 14 at patients and 18 at both. In general, descriptions of the tool types were hard to find or incomplete.

CONCLUSIONS

There exists a myriad of knowledge tool types and their descriptions are mostly unclear. The information overload experienced by clinicians is not addressed effectively by developing numerous unclearly defined knowledge tools. We recommend limiting the number of tool types and making a greater effort in clearly defining them. This abundance of poorly defined tools does not seem to be restricted to the Netherlands.

Implementation of pain best practices as part of the spinal cord injury knowledge mobilization network

Context/objective: The spinal cord injury (SCI) knowledge mobilization network (KMN) is a community of practice formed in 2011 as part of a national best practice implementation (BPI) effort to improve SCI care. This study objective was to determine whether completion and documentation of pain practices could be improved in a neurorehabilitation setting using the KMN implementation approach. Design: Single site, pre-post intervention study. Setting: Neurorehabilitation hospital. Participants: Twenty sequential consenting inpatients with SCI, with retrospective comparative analysis of 50 sequential SCI admissions pre-KMN. Interventions: A local Site Implementation Team (SIT) was formed to develop an implementation plan, including acceptable timeframes for completion and documentation of four specific pain best practices: (1) pain assessment on admission, (2) development of an Inter-Professional Pain Treatment Plan (IPTP), (3) pain monitoring throughout admission, and (4) a pain discharge plan. Outcomes: Provider adherences to pain best practices were the primary outcomes. The secondary outcome was patient satisfaction. Results: Provider adherence for most outcomes exceeded 70% completion within acceptable timeframes, with improvements found for all outcomes as compared to the retrospective cohort. Notably, pain education as part of the IPTP improved from 12% completion to 74%, documenting pain onset from 4.5% to 80% and pain discharge plan from 40% to 74%. Overall, participants were satisfied with their pain management. Conclusions: Pain best practices were more consistently documented after the KMN implementation. Pain practices in all four areas have now been expanded to all inpatient diagnoses using the same forms and framework created in the implementation process.

Barriers and enablers for the implementation of clinical practice guidelines in China: a mixed-method study

OBJECTIVES

The aim of this study was to explore perspectives and reasoning of medical staff from Class A tertiary hospitals about the factors hindering and facilitating the uptake and use of clinical practice guidelines (CPGs) during medical procedures.

DESIGN

Mixed-method research study to collect and analyse both quantitative and qualitative data.

SETTING

Class A tertiary hospitals in China.

PARTICIPANTS

The inclusion criteria for the questionnaire survey and qualitative research were (1) medical practitioners and (2) years of practice: above 5 years in a tertiary hospital.

METHODS

Questionnaires were distributed to medical staff in 11 cities to collect quantitative data. Frequency and ranking of barriers and enablers were analysed. Spearman correlations were computed to explore the correlation between years of practice, professional title ranking and educational background with self-reported guideline adherence. Using a constructivist grounded theory method, qualitative data were generated via in-depth face-to-face interviews with Chinese medical practitioners.

RESULTS

A total of 359 medical practitioners were surveyed and 32 medical practitioners interviewed in 11 cities. Higher frequency and higher ranking of barriers all converged on 'lack of access', 'less convenient', 'lack of applicability' and 'lack of evidence from Chinese sample'. Higher frequency and higher ranking of enablers converged on 'Short formats presentation', 'Utilisation of various media', 'Information visualisation' and 'Linking to patient electronic medical records'. There were no relationships between characteristics of respondents with self-reported adherence. This research produced a theoretical understanding of the experience of medical practitioners when using guidelines. Themes identified were as follows: existing intrinsic flaws in guidelines, deficient or incomplete system mechanism and being ambiguous.

CONCLUSION

Our findings provide a comprehensive and culturally sensitive perspective in understanding guideline implementation in China. Strategies addressing those barriers should be further discussed and researched in the future.

Nurses' Role in Implementing and Sustaining Acute Telemedicine: A Mixed-Methods, Pre-Post Design Using an Extended Technology Acceptance Model

PURPOSE

Technology-based systems like telemedicine are frequently being implemented into healthcare settings, impacting clinician practices. Little is known about factors influencing acute telemedicine uptake, if factors differ across time, or between nurses and non-nurses.

DESIGN

A mixed-methods, pre-post design with implementation of a new acute stroke telemedicine service.

METHODS

A survey based on an extended Technology Acceptance Model (TAM) was administered to clinicians involved in acute stroke care at 16 regional hospitals (2014-2017). Open-ended questions postimplementation (at 6 months) included strengths of the program and areas to improve. Subsequently, a secondary analysis of nurses' semistructured interviews at the first telemedicine site (2010-2011) was completed to provide greater explanatory detail.

FINDINGS

Surveys were completed by nurses (preimplementation n = 77, postimplementation n = 92) and non-nurses (pre n = 90, post n = 44). Preimplementation, perceived usefulness was the only significant predictor of intending to use telemedicine for nurses, while perceived ease of use and social influence were significant for non-nurses. Postimplementation, perceived usefulness was significant for both groups, as was facilitating conditions for nurses. Specific examples aligned to TAM categories from our detailed interviews (n = 11 nurses) included perceived usefulness (improved clinical support and patient care), perceived ease of use (technical, clinical aspects), facilitating conditions (setting, education, confidence), and social influence (working relationships).

CONCLUSIONS

Important factors for acute stroke telemedicine varied between nurses and non-nurses, and changed after implementation. The benefits of telemedicine should be emphasized to nurses. Preimplementation, more non-nurses wanted systems to be easy. Support in clinical, technical, and relationship aspects of telemedicine consultations is required.

CLINICAL RELEVANCE

Nurses are influential in implementing acute telemedicine, which is complex, with clinical and technical aspects entwined. Evidence-based implementation strategies must be tailored over time, and between nurses and non-nurses, to ensure initial uptake and ongoing use.

The implementation of change model adds value to value-based healthcare: a qualitative study

Background

Value-based healthcare (VBHC) is a concept that focuses on outcome measurement to contribute to quality improvement. However, VBHC does not offer a systematic approach for implementing improvement as implementation science does. The aim is to, firstly, investigate the implementation of improvement initiatives in the context of VBHC and secondly, to explore how implementation science could be of added value for VBHC and vice versa.

Methods

A case study with two cases in heart care was conducted; one without the explicit use of a systematic implementation method and the other one with the use of the Implementation of Change Model (ICM). Triangulation of data from document research, semi-structured interviews and a focus group was applied to evaluate the degree of method uptake. Interviews were held with experts involved in the implementation of Case 1 (N = 4) and Case 2 (N = 7). The focus group was held with experts also involved in the interviews (N = 4). A theory-driven qualitative analysis was conducted using the ICM as a framework.

Results

In both cases, outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation.

Conclusion

Application of the ICM facilitates successful implementation of quality- improvement initiatives within VBHC. However, the practical use of the ICM shows an emphasis on processes. We recommend that monitoring of outcomes be added as an essential part of the ICM. In the discussion, we propose an implementation model that integrates ICM within VBHC.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4498-y) contains supplementary material, which is available to authorized users.

Association of National Cancer Institute-Sponsored Clinical Trial Network Group Studies With Guideline Care and New Drug Indications

IMPORTANCE

National Cancer Institute Clinical Trial Network (NCTN) groups serve a vital role in identifying effective new antineoplastic regimens. However, the downstream clinical effect of their trials has not been systematically examined.

OBJECTIVE

To examine the association of NCTN trials with guideline care and new drug indications.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study evaluated phase 3 SWOG Cancer Research Network clinical trials from January 1, 1980, through June 30, 2017. Only completed trials with published results were included. To be considered practice influential (PI), a trial must have been associated with guideline care through its inclusion in National Comprehensive Cancer Network (NCCN) clinical guidelines or US Food and Drug Administration (FDA) new drug approvals in favor of a recommended treatment. Data were analyzed from June 15, 2018, through March 29, 2019.

MAIN OUTCOMES AND MEASURES

Estimated overall rate of PI trials, as well as trends over time. The total federal investment supporting the set of trials was also determined.

RESULTS

In total, 182 trials consisting of 148 028 patients were studied. Eighty-two studies (45.1%; 95% CI, 37.7%-52.6%) were PI, of which 70 (38.5%) influenced NCCN guidelines, 6 (3.3%) influenced FDA new drug approvals, and 6 (3.3%) influenced both. The number of PI trials was 47 of 65 (72.3%) among those with positive findings and 35 of 117 (29.9%) among those with negative findings. Thus, 35 of 82 PI trials (42.7%) were based on studies with negative findings, with nearly half of these studies (17 of 35 [48.6%]) reaffirming standard of care compared with experimental therapy. The total federal investment spent in conducting the trials was $1.36 billion (2017 US dollars), a rate of $7.5 million per study or $16.6 million per PI trial.

CONCLUSIONS AND RELEVANCE

Nearly half of all phase 3 trials by one of the NCTN's largest groups were associated with guideline care or new drug indications, including those with positive and negative findings. Compared with the costs of a new drug approval in pharmaceutical companies, typically estimated at more than $1 billion, the amount of federal funds invested to provide this valuable evidence was modest. These results suggest that the NCTN program contributes clinically meaningful, cost-efficient evidence to guide patient care.

Toward a health-promoting system for cancer survivors: Patient and provider multiple behavior change

OBJECTIVE

This paper examines how and why to improve care systems for disease management and health promotion for the growing population of cancer survivors with cardiovascular multi-morbidities.

METHOD

We reviewed research characterizing cancer survivors' and their multiple providers' common sense cognitive models of survivors' main health threats, preventable causes of adverse health events, and optimal coping strategies.

RESULTS

Findings indicate that no entity in the health care system self-identifies as claiming primary responsibility to address longstanding unhealthy lifestyle behaviors that heighten survivors' susceptibility to both cancer and cardiovascular disease (CVD) and whose improvement could enhance quality of life.

CONCLUSIONS

To address this gap, we propose systems-level changes that integrate health promotion into existing survivorship services by including behavioral risk factor vital signs in the electronic medical record, with default proactive referral to a health promotionist (a paraprofessional coach adept with mobile technologies and supervised by a professional expert in health behavior change). By using the patient's digital tracking data to coach remotely and periodically report progress to providers, the health promotionist closes a gap, creating a connected care system that supports, reinforces, and maintains accountability for healthy lifestyle improvement. No comparable resource solely dedicated to treatment of chronic disease risk behaviors (smoking, obesity, physical inactivity, treatment nonadherence) exists in current models of integrated care. Integrating health promotionists into care delivery channels would remove burden from overtaxed PCPs and instantiate a comprehensive, actionable systems-level schema of health risks and coping strategies needed to have preventive impact with minimal interference to clinical work flow. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Implementation of new guidelines in the prehospital services: a nationwide survey of Norway

Background

A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process.

Method

An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline.

Results

In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents.

Conclusion

Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0660-0) contains supplementary material, which is available to authorized users.

Patient and caregiver perspectives on guideline adherence: the case of endocrine and bone health recommendations for Duchenne muscular dystrophy

BACKGROUND

Clinical care guidelines are typically developed by clinicians and researchers. Including patient and caregiver voices in guideline development may help create guidelines that are more useful for patients and consequently improve their guideline adherence. Although there is substantial research on the factors the affect providers' adherence to guidelines, there is less research on the factors that affect patients' compliance with guideline recommendations, especially among those with rare disorders. The purpose of this study is to explore factors that are likely to affect patient/caregiver adherence to endocrine and bone health recommendations for Duchenne Muscular Dystrophy (DMD). To do so, we used qualitative data collected as part of the study designed to develop, implement, and evaluate a new online, modified-Delphi approach to engaging patients with rare diseases and their caregivers in guideline development, using care guidelines for DMD as a case study.

METHODS

We thematically analyzed qualitative data collected from 95 adults with DMD and their caregivers who participated in at least one round of our online Modified-Delphi panel process. Participants rated and commented on the patient-centeredness of 19 recommendations about vertical growth, weight management, bone health, and delayed puberty included in the 2018 DMD care considerations. Patient-centeredness was operationalized as the importance and acceptability of care recommendations.

RESULTS

Thematic analyses revealed six factors that affect guideline adherence from the patient/caregiver perspective: content and format of recommendations, patient and provider characteristics, and social and financial factors.

CONCLUSIONS

This study used a novel approach to exploring patient and caregiver perspectives on factors that may affect guideline adherence. The six factors identified by DMD patients and caregivers are similar to the factors affecting provider adherence and are not limited to DMD. Understanding consistency between provider- and patient/caregiver-identified barriers to following guideline recommendations can lead to developing more successful interventions for increasing guideline adherence.

Implementing guideline-checklists: Evaluating health care providers intentional behaviour using an extended model of the theory of planned behaviour

OBJECTIVES

Internationally, clinical guidelines as checklists are increasingly used in acute ward practice to standardize the delivery and raise the quality of care on acute hospital wards. However, when guideline-checklists are implemented repeatedly, health providers' intentions to carry out this type of behaviour are not well understood. Therefore, the objective of this study was to evaluate nurses' and health care assistants' (HCAs) intentions to implement a "care round checklist"; a guideline-intervention repeated hourly on hospital wards. Furthermore, an extended Theory of Planned Behaviour (TPB) model's usefulness in explaining this type of behaviour was also evaluated.

METHODS

A theory-informed questionnaire, guided by the TPB, habit, and clinical context variables, was developed to measure the guideline-checklist behaviour. Quantitative questionnaire data were analysed using descriptive and inferential tests to establish differences in nurses' and HCAs' intentions and the predictive value of the model.

RESULTS

A sample of 270 nurses and HCAs returned questionnaires from 24 wards in a major hospital in England. The extended TPB model explained 20% of nurses and 24% of HCAs reported intentions to implement a care round checklist, a modest proportion of intent. Attitude and perceived control best predicted nurses' intentions, and attitude and practice habit HCAs' intentions. TPB belief variables helped explain why nurses and HCAs intentions were different.

CONCLUSIONS

Statistically, the extended TPB model highlighted that nurses and HCAs intentions to implement this type of guideline are predicted by different variables. This implied professional "role" as an important variable in explaining differences in intentions, which should be evaluated and integrated into the future design of this type of checklist. Further variables could be added to explain and learn more about intentional thinking for this type of behaviour and should help to develop a theoretical understanding of intentions underpinning this type of behaviour and ultimately improve patient care.

Design features of a guideline implementation tool designed to increase awareness of a clinical practice guide to HIV rehabilitation: A qualitative process evaluation

RATIONALE, AIMS, AND OBJECTIVES

A comprehensive electronic guide (e-module) describing an interprofessional, evidence-informed approach to HIV rehabilitation was developed as an education resource for rehabilitation professionals. We developed a guideline implementation tool, consisting of a 10-week, case-based education intervention delivered by email, that was perceived to increase rehabilitation professionals' (occupational therapists (OTs), physical therapists (PTs), and speech language pathologists (SLPs)) knowledge and confidence to apply best practices in HIV rehabilitation. This study aimed to increase understanding of how the design of the guideline implementation tool facilitated increased awareness of and access to the e-module among rehabilitation professionals.

METHODS

We conducted a single group intervention study with rehabilitation professionals in Canada and the United Kingdom. Six case studies targeting HIV pathophysiology and associated conditions, an interprofessional approach to rehabilitation assessment and treatment, and psychosocial issues experienced by people living with HIV, were emailed to participants at 2-week intervals. Individual semi-structured interviews were conducted post-intervention. Interview transcripts were analysed using a descriptive qualitative approach.

RESULTS

Twenty-six individuals (17 from Canada, and 9 from the UK; 16 PTs, 7 OTs, 3 SLPs) were interviewed. One main theme related to design features of the intervention that facilitated learning and access to the e-module emerged. Subthemes highlighted features of the case-based intervention, including technical feasibility, terminology, formatting and layout, hyperlinks, number and frequency of case studies, and diverse and realistic case scenarios relevant to the learner's practice, that participants described as facilitating access to information and learning.

CONCLUSION

Electronically administered case studies were perceived as complementary knowledge tools that increased access to an evidence-informed guide to HIV rehabilitation. Findings provide guidance on using case studies as a guideline implementation tool to facilitate access to information and related resources to optimize learning.