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McMullen CA, Williams MV, Smyth SS, Clouser JM, Li J. Co-designing and piloting educational materials with patients and healthcare providers for syncope in the emergency department. PEC INNOVATION 2023; 2:100131. [PMID: 37214525 PMCID: PMC10194231 DOI: 10.1016/j.pecinn.2023.100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 05/24/2023]
Abstract
Objective The purpose of this study was to identify barriers and design interventions to promote adherence to 2017 Guideline for Syncope Evaluation and Management. Methods Focus groups and interviews were conducted to understand preferences, needs and barriers from patients and providers. Educational materials for patients were developed following a co-design, iterative process with patients, providers and hospital staff. The academic medical center's (AMC) Patient Education Department and Patient & Family Advisory Council reviewed materials to ensure health literacy. We piloted usability and feasibility of delivering the materials to a small cohort of patients. Results From Feb to March 2020, 24 patients were asked to watch the video. Twenty-two watched the intake video; of those 8 watched the discharge video. 95% of participants found the intake video informational and 86% would recommend it to others; 100% found the discharge video informational and would recommend it to others. Patients who watched both videos reported the videos improved their overall stay. Conclusion Our study described a patient-clinician-researcher codesign process and demonstrated feasibility of tools developed to communicate risk and uncertainty with patients and facilitate shared decision making in syncope evaluation. Innovation Engaging end users in developing interventions is critical for sustained practice change.
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Affiliation(s)
- Colleen A. McMullen
- Department of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 40536 Lexington, KY, United States of America
| | - Mark V. Williams
- Department of Medicine, Washington University, 600 S Taylor Ave, 155K, St Louis, MO 63110, USA
| | - Susan S. Smyth
- Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205, USA
| | - Jessica Miller Clouser
- Department of Behavioral Science, College of Medicine, University of Kentucky, 1100 Veterans Drive, Lexington, KY, USA
| | - Jing Li
- Department of Medicine, Washington University, 600 S Taylor Ave, 155K, St Louis, MO 63110, USA
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O’Leary P, Domeracki A, Raymond J, Kozhumam A, Macha V, Sakita F, Krym V, Riccardo Nickenig Vissoci J, Staton C. A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002154. [PMID: 38016001 PMCID: PMC10684081 DOI: 10.1371/journal.pgph.0002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/18/2023] [Indexed: 11/30/2023]
Abstract
Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.
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Affiliation(s)
- Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alexis Domeracki
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Arthi Kozhumam
- Northwestern University Feinburg School of Medicine, Chicago, Illinois, United States of America
| | | | | | - Valerie Krym
- Department of Emergency Medicine, University of Toronto Medical School, Toronto, Ontario, Canada
| | - Joao Riccardo Nickenig Vissoci
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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Bradshaw S, Graco M, Holland A. Barriers and facilitators to guideline-recommended care of benign paroxysmal positional vertigo in the ED: a qualitative study using the theoretical domains framework. Emerg Med J 2023; 40:335-340. [PMID: 36792342 DOI: 10.1136/emermed-2022-212585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common presentation to the ED. Evidence suggests low adherence to guideline-recommended care, but the reasons underlying this are poorly understood. This study used the theoretical domains framework (TDF) to explore the barriers and facilitators to medical and physiotherapy clinical practices in the management of BPPV in an Australian metropolitan ED. METHODS From May to December 2021, semistructured interviews were conducted with 13 medical staff and 13 physiotherapists who worked at an ED in Melbourne, Australia. Interviews used the TDF to explore the perceived barriers and facilitators to the delivery of guideline-recommended assessment and treatment techniques for BPPV. Data were analysed thematically to identify relevant domains and generate themes and belief statements. RESULTS Fifteen belief statements representing eight domains of the TDF were identified as key factors in the management of BPPV in the ED. The most prominent domains were knowledge and skills due to their conflicting belief statements between professions concerning education, skill development and self-confidence; memory, attention and decision processes for the perceived complexity of the presentation including difficulty recalling diagnostic and treatment techniques; and environmental context and resources for their shared belief statements concerning time and workload pressures. The availability of vestibular physiotherapy was considered both a barrier and facilitator to the delivery of recommended care by medical staff, but a barrier to independent practice as it unintentionally limited the opportunities for skill development in medical staff. CONCLUSION Several modifiable barriers and facilitators to the management of BPPV in the ED have been identified. Differences were observed between the professional groups, and these findings will guide a future intervention to improve the use of guideline-recommended assessment and treatment techniques for BPPV in ED.
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Affiliation(s)
- Sally Bradshaw
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia .,School of Allied Health, La Trobe University, Bundoora Campus, Melbourne, Victoria, Australia.,Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Marnie Graco
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Respiratory Research, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Amin S, Gupta V, Du G, McMullen C, Sirrine M, Williams MV, Smyth SS, Chadha R, Stearley S, Li J. Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool. J Med Internet Res 2021; 23:e25192. [PMID: 34783669 PMCID: PMC8663445 DOI: 10.2196/25192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/05/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Syncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking. OBJECTIVE With input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis. METHODS Development of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability. RESULTS The MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool. CONCLUSIONS The MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development.
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Affiliation(s)
- Shiraz Amin
- Performance Analytics Center of Excellence, University of Kentucky HealthCare, Lexington, KY, United States
| | - Vedant Gupta
- Department of Cardiovascular Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Gaixin Du
- Center for Health Services Research, University of Kentucky, Lexington, KY, United States
| | - Colleen McMullen
- Department of Cardiovascular Medicine, University of Kentucky HealthCare, Lexington, KY, United States.,Gill Heart & Vascular Institute, University of Kentucky HealthCare, Lexington, KY, United States
| | - Matthew Sirrine
- Center for Health Services Research, University of Kentucky, Lexington, KY, United States
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan S Smyth
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Romil Chadha
- Division of Hospital Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Seth Stearley
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY, United States
| | - Jing Li
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
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Clouser JM, Sirrine M, McMullen CA, Cowley AM, Smyth SS, Gupta V, Williams MV, Li J. "Passing Out is a Serious Thing": Patient Expectations for Syncope Evaluation and Management. Patient Prefer Adherence 2021; 15:1213-1223. [PMID: 34113084 PMCID: PMC8187096 DOI: 10.2147/ppa.s307186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/05/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Syncope is a complex symptom requiring thoughtful evaluation. The ACC/AHA/HRS published syncope management guidelines in 2017. Effective guideline implementation hinges on overcoming multilevel barriers, including providers' perceptions that patients prefer aggressive diagnostic testing when presenting to the emergency department (ED) with syncope, which conflicts with the 2017 Guideline on Syncope. To better understand this perceived barrier, we explored patient and family caregiver expectations and preferences when presenting to the ED with syncope. PATIENTS AND METHODS We conducted semi-structured focus groups (N=12) and in-depth interviews (N=19) with patients presenting to the ED with syncope as well as with their family caregivers. Interviews were recorded, transcribed verbatim, and analyzed by a team of researchers following a directed content analysis. Results were reviewed and shared iteratively with all team members to confirm mutual understanding and agreement. RESULTS Syncope patients and caregivers discussed three main desires when presenting to the ED with syncope: 1) clarity regarding their diagnosis,; 2) context surrounding their care plan and diagnostic approach; and 3) to feel seen, heard and cared about by their health care team. CONCLUSION Clinicians have cited patient preferences for aggressive diagnostic testing as a barrier to adhering to the 2017 Guideline on Syncope, which recommends against routine administration of imaging testing (eg, echocardiograms). Our results suggest that while participants preferred diagnostic testing as a means to achieve clarity and even a feeling of being cared for, other strategies, such as a patient-engaged approach to communication and shared decision-making, may address the spectrum of patient expectations when presenting to the ED with syncope while adhering to guideline recommendations.
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Affiliation(s)
| | - Matthew Sirrine
- Center for Health Services Research, College of Medicine, Lexington, KY, USA
| | - Colleen A McMullen
- Gill Heart & Vascular Institute, UK HealthCare, Lexington, KY, USA
- Department of Cardiovascular Medicine, College of Medicine, Lexington, KY, USA
| | - Amy M Cowley
- Center for Health Services Research, College of Medicine, Lexington, KY, USA
| | - Susan S Smyth
- Gill Heart & Vascular Institute, UK HealthCare, Lexington, KY, USA
- Department of Cardiovascular Medicine, College of Medicine, Lexington, KY, USA
- Lexington Veterans Affairs Health Care System, College of Medicine, Lexington, KY, USA
| | - Vedant Gupta
- Gill Heart & Vascular Institute, UK HealthCare, Lexington, KY, USA
- Department of Cardiovascular Medicine, College of Medicine, Lexington, KY, USA
| | - Mark V Williams
- Center for Health Services Research, College of Medicine, Lexington, KY, USA
- Division of Hospital Medicine, UK HealthCare, University of Kentucky, Lexington, KY, USA
| | - Jing Li
- Center for Health Services Research, College of Medicine, Lexington, KY, USA
- Department of Cardiovascular Medicine, College of Medicine, Lexington, KY, USA
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8
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Li J, Smyth SS, Clouser JM, McMullen CA, Gupta V, Williams MV. Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:570. [PMID: 34204986 PMCID: PMC8228757 DOI: 10.3390/medicina57060570] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders' inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.
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Affiliation(s)
- Jing Li
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Susan S. Smyth
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Jessica M. Clouser
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
| | - Colleen A. McMullen
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Vedant Gupta
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Mark V. Williams
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
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