Proyecto de implantación de Guías de Buenas Prácticas en España 2011-2016

SUMAMOS EXCELENCIA® Project: Results of the Implementation of Best Practice in a Spanish National Health System (NHS)

The use of certain strategies for the implementation of a specific recommendation yields better results in clinical practice. The aim of this study was to assess the effectiveness of an evidence-based model using clinical audits (GRIP model), for the implementation of recommendations in pain and urinary incontinence management as well as fall prevention, in the Spanish National Health System during the period 2015-2018. A quasi-experimental study has been conducted. The subjects were patients treated in hospitals, primary care units and nursing home centers. There were measures related to pain, fall prevention and urinary incontinence. Measurements were taken at baseline and at months 3, 6, 9, and 12. The sample consisted of 22,114 patients. The frequency of pain assessment increased from 59.9% in the first cycle to a mean of 71.6% in the last cycle, assessments of risk of falling increased from 56.8% to 87.8% in the last cycle; and finally, the frequency of assessments of urinary incontinence increased from a 43.4% in the first cycles to a mean of 62.2% in the last cycles. The implementation of specific evidence-based recommendations on pain, fall prevention, and urinary incontinence using a model based on clinical audits improved the frequency of assessments and their documentation.

Using the Knowledge-to-Action Framework to understand experiences of breastfeeding guideline implementation: A qualitative study

AIM

To examine the perceptions and experiences of health care professionals and mothers in relation to the implementation of a breastfeeding clinical practice guideline (CPG).

BACKGROUND

Breastfeeding CPG applications remain limited, and qualitative studies have indicated the need to overcome the perception by professionals of difficulties in applying recommendations.

METHODS

A qualitative study was conducted in a Spanish public hospital that implemented the Registered Nurses´ Association of Ontario breastfeeding CPG from 2012 through 2015. Between May and August 2017, 27 semi-structured interviews were conducted with managers, with professionals in maternity and paediatric departments and with mothers. Deductive content analysis was performed following the stages in the Knowledge-To-Action (KTA) Framework.

RESULTS

We obtained five main categories: (a) problem as opportunity; (b) adequate context and adapted recommendations; (c) extent of implementation; (d) impact of results; and (e) knowledge use normalization.

CONCLUSIONS

The KTA Framework assists understanding of the participation of the main actors in breastfeeding CPG implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

The nature of the interventions and the participation of managers, different professionals and mothers in a multi-unit setting generate a complex implementation process that reveals key factors to be taken into account in future CPG implementations.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

International institutions facilitate the contact of health professionals to evidence-based recommendations for promoting exclusive breast feeding (BF). However, the achievement of good rates of exclusive BF is still far from the optimum. The intention of the present work is to determine the barriers identified by managers and health professionals involved in the implementation and sustainability of Clinical Practice Guidelines (CPG) for breastfeeding under the auspices of the Best Practice Spotlight Organization program. A qualitative research study was carried out. The participants were managers, healthcare assistants, nurses, midwives, pediatricians and gynecologists. Semi-structured interviews were conducted which were transcribed and analyzed using the six steps of thematic analysis. Twenty interviews were conducted, which defined four major themes: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; and (4) The mother and her surroundings. This research identifies the barriers perceived by the health professionals involved in the implementation, with the addition of the managers as well. Novel barriers appeared such as the ambivalent role of the midwives and the fact that this CPG is about promoting health. The efforts for promoting the implementation program should be continuous, and the services should be extended to primary care.

Implementation experience of a guideline on fall prevention in Centres Committed to Excellence in Care®

AIM

To describe the progress of implementing the «Preventing falls» Guideline of the Best Practice Spotlight Organization (BPSO®) Programme and fall outcomes in Centres Committed to Excellence in Care (CCEC®).

METHOD

A Quasi-experimental study pre-post test from a multicentric approach carried out between 2012-2018. The study is focused on patients aged 65 or older, discharged from guideline implementation units, analysing sociodemographic variables (sex, age, hospitalization days; fall risk assessment on admission and patient in risk; fall prevention plan; incidence of falls. Data was compared from CCEC® programme indicators measured over the periods: baseline (T1), candidate during the first three years (T2), and sustainability (T3). Descriptive and inferential analysis was performed.

RESULTS

31,486 patients were evaluated in 7 centres (T1=465; T2=14,255; T3=16,766). Of the patients, 51.87% were men and average age was 79.06 years. Hospitalization was 8.15 days. Fall risk assessment on admission was performed in 81.96% of patients (T1=44.30%, T2=81.11%, T3=83.73%) and 52.31% patients had high risk. A prevention falls plan was registered in 47.75% of patients (T1=24.73%, T2=42.43%, T3=52.90%). Four hundred and twenty-three falls were recorded, 62.17% without injuries.

CONCLUSIONS

Despite the differences between hospitals, such as structural characteristics, strategies, assessment tools and data progression pace; adherence to recommendations is proving successful, improving widely. Guideline implementation has allowed fall problems to be addressed, producing positive changes in the process and encouraging the implementation and sustainability of evidence-based nursing practice.

Implementation of the best practice guideline for pressure ulcer prevention: Development, results and sustainability

AIM

To assess the impact of implementing the "Risk Assessment and Prevention of Pressure Injuries (PI)" guideline on adherence to its recommendations, the prevalence of PI and the sustainability of results, and to analyse the implementation strategies, sustainability and barriers detected.

METHODS

A retrospective observational study (June 2015 to December 2018). Two periods were studied (P1: Preparation and P2: Sustainability). The programme reports and data from the medical records of patients discharged from the 4participating hospitals were analysed with regard to adherence to preventive recommendations and health outcomes in terms of the presence of pressure injuries per centre.

RESULTS

A total of 13,515 patients were included, of whom 4,523 were at risk for PI and 722 had PI. Of the patients, 82.9% underwent a risk assessment for PI on admission. A decrease in this assessment on admission was observed between P1:89.1% vs. P2: 81% P<.001. Of the patients at risk, 42.1% were reassessed during their admission and a significant increase was observed between the periods P1: 30.7% vs. P2:46%; P<.001. 63.2% had a special pressure management surface, with a significant increase between P1:55.3% vs. P2: 65%; P<.001. The overall prevalence of PI was 5.5% and a significant decrease was observed on comparing P1: 6.6% vs. P2:5.1%; P=.003. The prevalence of nosocomial PI remained constant at 2.1%, P1:2% and P2:2.1%; P=.708. Institutional commitment, the appointment of leaders, drawing up of action plans, and training are outstanding strategies in all the centres.

CONCLUSIONS

This study shows that there is adequate adherence to the main recommendations of the guideline. A statistically significant improvement was observed in adherence to 2 out of the 3 recommendations assessed. The implantation and sustainability strategies implemented have been contributed to maintenance and/or improving results over time.

Evaluation of implementation strategies of the Best Practices Spotlight Organisations (BPSO) Project in Spain

OBJECTIVE

To identify favourable elements and barriers to implementation in the Program of Best Practice Spotlight Organization® that establish clinical practice guidelines of the Registered Nurse' Association of Ontario, so that future experiences could benefit from the assessments presented here.

METHOD

Evaluation research study of the process of implementing guidelines in institutions that make up the first two cohorts of the programme in Spain, through analysis of contents of implantation reports and inductive process, reading, interpretation, coding and categorized according to SWOT structure: Strengths, weaknesses, opportunities and threats.

RESULTS

Reports from 18 centres in 12 Autonomous Communities have been analyzed, including 22 different guidelines. As weaknesses, problems related to information systems and their exploitation stand out for frequency and intensity. Other elements related to dissemination of results, to professionals, care and factors related to the institution are presented. Standing out as threats are the instability of staff and continued changes in Senior Management or corporate policies. Among the strengths, the exclusive dedication of personnel to the project and its link to institutional objectives are distinguished. As opportunities, the possibility of standardized comparison of own results with others, as well as the dissemination of results are highlighted.

CONCLUSION

A useful pattern is set up to approach implementation in other scenarios, where changes in professional culture, training, communication and leadership, as well as aligning interests of managers and politicians, facilitate ideal conditions for Evidence-Based Practice.

The SUMAMOS EXCELENCIA Project

AIM

The gap between research and clinical practice leads to inconsistent decision-making and clinical audits are an effective way of improving the implementation of best practice. Our aim is to assess the effectiveness of a model that implements evidence-based recommendations for patient outcomes and healthcare quality.

DESIGN

National quasi-experimental, multicentre, before and after study.

METHODS

This study focuses on patients attending primary care and hospital care units and associated socio-healthcare services. It uses the Joanna Brigg's Institute Getting Research into Practice model, which improves processes by referring to prior baseline clinical audits. The variables are process and outcome criteria for pain, urinary incontinence, and fall prevention, with data collection at baseline and key points over 12 months drawn from clinical histories and records. Project funding was received from the Spanish Strategic Health Action in November 2014.

DISCUSSION

The project results will provide knowledge on the effectiveness of the Getting Research into Practice model, to apply evidence-based recommendations for the detection and management of pain, urinary incontinence, and fall prevention. It will also establish whether using research results, based on clinical audits and situation analysis, is effective for implementing evidence-based recommendations and improving patients' health.

IMPACT

This nationwide Spanish project aims to detect and prevent high-prevalence healthcare problems, namely pain in patients at any age and falls and urinary incontinence in people aged 65 and over. Tailoring clinical practice to evidence-based recommendations will reduce unjustified clinical variations in providing healthcare services. Clinical Trial ID: NCT03725774.

Factors associated with breastfeeding support from health care professionals by implementing a Clinical Practice Guideline

BACKGROUND

The prevalence and duration of breastfeeding are at low levels and may be improved by the support of health care professionals. Our objective was to determine the effect of implementing a breastfeeding clinical practice guideline on factors associated with breastfeeding support by health care professionals, adopting a Theory of Planned Behavior approach.

METHODS

We conducted an observational, cross-sectional study during 2016 in a health area with implemented clinical practice guideline on breastfeeding, comparing the results with data from a previous cross-sectional study (2011) in the same area, in a standard-care area, and in a Baby-Friendly Hospital Initiative (BFHI)-accredited area. A validated questionnaire (four scales: attitudes, beliefs, subjective norms, and behavioral intention) was completed by professionals in each area. Descriptive analysis was followed by comparisons among the different settings using the chi-square test.

RESULTS

In the area with the implemented clinical practice guideline, the professionals scored significantly higher in subjective norms and beliefs than had been recorded in 2011 (preimplementation), and their scores for all four scales were significantly higher than in the standard-care area. Professionals obtained significantly higher scores for subjective norms in the BFHI-accredited area than in the other settings.

CONCLUSIONS

Clinical practice guideline implementation improved the responses of professionals on breastfeeding support in subjective norms and beliefs scales. There is a need for activities to assist breastfeeding in a practical manner and for more effective measures to ensure compliance with the International Code of Marketing of Breast-milk Substitutes.

[Implementing evidence and implementation research: two different and prime realities]

Scientific research can contribute to more efficient health care, enhance care quality and safety of persons. In order for this to happen, the knowledge gained must be put into practice. Implementation is known as the introduction of a change or innovation to daily practice, which requires effective communication and the elimination of barriers that hinder this process. Best practice implementation experiences are being used increasingly in the field of nursing. The difficulty in identifying the factors that indicate the success or failure of implementation has led to increased studies to build a body of differentiated knowledge, recognized as implementation science or implementation research. Implementation research is the scientific study whose objective is the adoption and systematic incorporation of research findings into clinical practice to improve the quality and efficiency of health services. The purpose of implementation research is to improve the health of the population through equitable and effective implementation of rigorously evaluated scientific knowledge, which involves gathering the evidence that has a positive impact on the health of the community. In this text, we set out the characteristics of nursing implementation research, providing a synthesis of different methods, theories, key frameworks and implementation strategies, along with the terminology proposed for greater conceptual clarity.

[Implementation of a best practice guideline for the prevention of falls: Perception among hospitalized patients and its caregivers]

OBJECTIVE

To analyze the influence that the implementation of a fall prevention Best Practice Guideline (BPG) could have on the perception of patients and their caregivers about the utility of the activities implemented, about the care provided during admission and the adherence (the level of follow-up) to the recommendations received at discharge.

MATERIAL AND METHOD

Design. Quasi-experimental study. Patients >65 years admitted≥48h to the Medical Area of the General Hospital of Albacete.

SAMPLE

104 subjects (consecutive sampling January-March 2013). Experimental group (EG). Patients admitted to BPG implementation units. Control group (CG). Usual care units.

VARIABLES

Sociodemographic characteristics; previous and during admission falls, cognitive status (Pfeiffer); independence in daily life activities (ADLs); satisfaction with care and information provided, utility perceived, adherence to recommendations at discharge.

DATA SOURCES

Interview and clinical history. Statistical analysis (SPSS 15.0). Descriptive and bivariant. Relative Risk. CI95%.

RESULTS

104 patients, EG 46.2% (48) and CG 53.8% (56). Women 51.9%, average age 79.9 years (s.d.=7.8). Pfeiffer 4,3 (s.d.=3.7). Previous falls 31.1%. In process, 1 fall in each group. There were statistically significant differences between EG/CG: age, cognitive status and independence in ADLs. In the EG was higher the percentage of perception about the usefulness of the recommendations to prevent falls (P<.001), greater adherence to them (P=0.0002), and to be very or quite satisfied with the information (P<.00004) and care received (P=.002).

CONCLUSION

To implement recommendations according to an Evidence-based BPG to prevent falls in older people has shown, in users and caregivers, greater satisfaction, better perception of its usefulness and greater adherence to the recommendations.

[Evidence-based practice competence in undergraduate Nursing Degree students]

AIM

Evidence-based practice (EBP) learning has become a key issue for nurses. An EPB subject was included in the 4(th) year in the new syllabus of the Nursing Degree at University of Murcia (UM). To know the competence level in EBP of undergraduate nursing students at UM and compare the results between all four years.

METHOD

Observational descriptive study with a cross-sectional approach.

STUDY POPULATION

undergraduate nursing students from all four years at Nursing Degree at the Faculty of Social and Healthcare Science at UM in the year 2013-14. EBP evaluation of competence of the nursing students consisted of attitude, skills and knowledge on EBP. A validated questionnaire, the EBP-COQ, was used. The scale range is 1 point «lowest level» to 5 points «higher level».The SPSS 21.0 program has been used to carry out descriptive and bivariate analyses.

RESULTS

144 students were included, 76.4% was female, and the median age was 23 years, 84.7% attended more than 75% class hours. The mean differences in the questionnaire between first and fourth years were 0.58 points in attitude, 0.60 in skills, 1.6 in knowledge and 0.83 in global competence in EBP. Significant differences in mean scores between the fourth and the remaining years in the global competence in EBP were observed, as well as in the three dimensions (p <0.05).

CONCLUSION

The undergraduate-nursing students studied here have acquired an appropriate competence level in EBP, with a gradual increase by year. The biggest increase was in the fourth year students.