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Implementation strategies in emergency management of children: A scoping review. PLoS One 2021; 16:e0248826. [PMID: 33761525 PMCID: PMC7990517 DOI: 10.1371/journal.pone.0248826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children. METHODS We conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies. RESULTS We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%). CONCLUSIONS Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.
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Homaira N, Wiles LK, Gardner C, Molloy CJ, Arnolda G, Ting HP, Hibbert P, Boyling C, Braithwaite J, Jaffe A. Assessing appropriateness of paediatric asthma management: A population-based sample survey. Respirology 2019; 25:71-79. [PMID: 31220876 DOI: 10.1111/resp.13611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/11/2019] [Accepted: 04/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE We conducted a comprehensive assessment of guideline adherence in paediatric asthma care, including inpatient and ambulatory services, in Australia. METHODS National and international clinical practice guidelines (CPG) relating to asthma in children were searched and 39 medical record audit indicator questions were developed. Retrospective medical record review was conducted across hospital inpatient admissions, emergency department (ED) presentations, general practice (GP) and paediatrician consultations in three Australian states for children aged ≤15 years receiving care in 2012 and 2013. Eligibility of, and adherence to, indicators was assessed from medical records by nine experienced and purpose-trained paediatric nurses (surveyors). RESULTS Surveyors conducted 18 453 asthma indicator assessments across 1600 visits for 881 children in 129 locations. Overall, the adherence for asthma care across the 39 indicators was 58.1%, with 54.4% adherence at GP (95% CI: 46.0-62.5), 77.7% by paediatricians (95% CI: 40.5-97.0), 79.9% in ED (95% CI: 70.6-87.3) and 85.1% for inpatient care (95% CI: 76.7-91.5). For 14 acute asthma indicators, overall adherence was 56.3% (95% CI: 47.6-64.7). Lowest adherences were for recording all four types of vital signs in children aged >2 years presenting with asthma attack (15.1%, 95% CI: 8.7-23.7), and reviewing patients' compliance, inhaler technique and triggers prior to commencing a new drug therapy (20.5%, 95% CI: 10.1-34.8). CONCLUSION The study demonstrated differences between existing care and CPG recommendations for paediatric asthma care in Australia. Evidence-based interventions to improve adherence to CPG may help to standardize quality of paediatric asthma care and reduce variation of care.
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Affiliation(s)
- Nusrat Homaira
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Respiratory Department, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Louise K Wiles
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute, University of South Australia, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Claire Gardner
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute, University of South Australia, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Charlotte J Molloy
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute, University of South Australia, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Gaston Arnolda
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Hsuen P Ting
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Peter Hibbert
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute, University of South Australia, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.,Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Claire Boyling
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Adam Jaffe
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Respiratory Department, Sydney Children's Hospital, Sydney, NSW, Australia
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Curran JA, Gallant AJ, Zemek R, Newton AS, Jabbour M, Chorney J, Murphy A, Hartling L, MacWilliams K, Plint A, MacPhee S, Bishop A, Campbell SG. Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis. Syst Rev 2019; 8:83. [PMID: 30944038 PMCID: PMC6446263 DOI: 10.1186/s13643-019-0995-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/22/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research. METHODS We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings. RESULTS A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice. CONCLUSION Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42014007106.
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Affiliation(s)
- Janet A. Curran
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Allyson J. Gallant
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Roger Zemek
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Amanda S. Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Jill Chorney
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Murphy
- College of Pharmacy, Dalhousie University, 5869 University Avenue, PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Kate MacWilliams
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Amy Plint
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Shannon MacPhee
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Samuel G. Campbell
- Charles V. Keating Emergency and Trauma Centre, QEII Health Sciences Centre, 1796 Summer St, Halifax, NS B3H 3A7 Canada
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Adjemian R, Moradi Zirkohi A, Coombs R, Mickan S, Vaillancourt C. Are emergency department clinical pathway interventions adequately described, and are they delivered as intended? A systematic review. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517732507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction The accurate reproduction of clinical interventions and the evaluation of provider adherence in research publications improve the evaluation and implementation of research findings into clinical practice. We sought to examine the proportion of clinical pathway publications in an emergency department setting that adequately reported the following: (1) the exact reproduction of the clinical pathway that was implemented in the study, (2) the adherence to and correct execution of the clinical pathway intervention, and (3) the presence of a pre-implementation education phase. Methods We performed a descriptive systematic review of the literature from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. Validated clinical pathway criteria were used to identify relevant publications. Two reviewers independently collected data using a piloted data abstraction tool. Risk of bias was assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Tool and the Newcastle-Ottawa Scale. Results We identified 5947 publications, 44 of which met our inclusion criteria. The formal clinical pathway was fully reproduced in 27 (61%) publications, partially reproduced in 9 (21%), and not reproduced in 8 (18%). Only 14 (32%) studies reported whether at least one decision step was executed correctly. The presence of a pre-implementation education phase was reported in 33 (75%) studies. Conclusion The underreporting of intervention elements may present a barrier to both the evaluation and accurate replication of clinical pathway interventions. These finding may be useful for the elaboration of complex intervention reporting guidelines, improved reporting in future clinical pathway publications, and improved knowledge translation and exchange of clinical pathway interventions.
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Affiliation(s)
- Raffi Adjemian
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Department of Family Medicine, McGill University, Quebec, Canada
| | | | - Robin Coombs
- Department of Family Medicine, McGill University, Quebec, Canada
| | - Sharon Mickan
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Gold Coast Health, Griffith University, Gold Coast, Australia
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Adjemian R, Zirkohi AM, Coombs R, Mickan S, Vaillancourt C. Validation of descriptive clinical pathway criteria in the systematic identification of publications in emergency medicine. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517707971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Heterogeneity in both the definition and terminology of clinical pathways presents a challenge to the systematic identification of primary studies for review purposes. Recently developed clinical pathway identification criteria may facilitate both the identification and assessment of clinical pathway studies. The goal of this publication is the validation of these five criteria in a descriptive systematic review of actively implemented clinical pathway studies in the emergency department setting. The main outcome measure is the inter-rater agreement of investigators using the clinical pathway criteria. Methods We performed a systematic literature search from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. We identified relevant publications using the above-mentioned clinical pathway criteria. Two reviewers independently collected data using a piloted data abstraction tool. Results We identified 5947 publications, with 472 potentially relevant full text publications retrieved. Of these, 357 did not meet preliminary study inclusion criteria, leaving 115 publications where the clinical pathway criteria were applied. Ultimately, 44 publications were included. The inter-rater agreement of the criteria was very good (κ = 0.81, 95% Confidence Interval = 0.70–0.92). The vast majority of studies were excluded because the intervention did not meet the criterion of being multidisciplinary in nature. Conclusion These criteria are a useful instrument to reliably identify clinical pathway publications for systematic review purposes in an emergency department setting. Future modification of these criteria may improve their usefulness. Particular attention should be placed on clarifying what is meant by multidisciplinary involvement within the context of clinical pathway interventions, with specific emphasis placed on delineating the level of involvement of each discipline and their decision-making responsibility.
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Affiliation(s)
| | | | | | - Sharon Mickan
- University of Oxford, UK
- Griffith University, Australia
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Curran JA, Taylor A, Chorney J, Porter S, Murphy A, MacPhee S, Bishop A, Haworth R. Development and feasibility testing of the Pediatric Emergency Discharge Interaction Coding Scheme. Health Expect 2017; 20:734-741. [PMID: 28078763 PMCID: PMC5513006 DOI: 10.1111/hex.12512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2016] [Indexed: 11/28/2022] Open
Abstract
Background Discharge communication is an important aspect of high‐quality emergency care. This study addresses the gap in knowledge on how to describe discharge communication in a paediatric emergency department (ED). Objective The objective of this feasibility study was to develop and test a coding scheme to characterize discharge communication between health‐care providers (HCPs) and caregivers who visit the ED with their children. Design The Pediatric Emergency Discharge Interaction Coding Scheme (PEDICS) and coding manual were developed following a review of the literature and an iterative refinement process involving HCP observations, inter‐rater assessments and team consensus. Setting and participants The coding scheme was pilot‐tested through observations of HCPs across a range of shifts in one urban paediatric ED. Main variables studied Overall, 329 patient observations were carried out across 50 observational shifts. Inter‐rater reliability was evaluated in 16% of the observations. The final version of the PEDICS contained 41 communication elements. Results Kappa scores were greater than .60 for the majority of communication elements. The most frequently observed communication elements were under the Introduction node and the least frequently observed were under the Social Concerns node. HCPs initiated the majority of the communication. Conclusion Pediatric Emergency Discharge Interaction Coding Scheme addresses an important gap in the discharge communication literature. The tool is useful for mapping patterns of discharge communication between HCPs and caregivers. Results from our pilot test identified deficits in specific areas of discharge communication that could impact adherence to discharge instructions. The PEDICS would benefit from further testing with a different sample of HCPs.
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Affiliation(s)
- Janet A Curran
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
| | | | - Jill Chorney
- Department of Anesthesia, Dalhousie University, Halifax, NS, Canada
| | - Stephen Porter
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Murphy
- Department of Psychiatry & College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Shannon MacPhee
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Rebecca Haworth
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Wilson CL, Johnson D, Oakley E. Knowledge translation studies in paediatric emergency medicine: A systematic review of the literature. J Paediatr Child Health 2016; 52:112-25. [PMID: 27062613 DOI: 10.1111/jpc.13074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/19/2015] [Accepted: 09/27/2015] [Indexed: 11/29/2022]
Abstract
AIM Systematic review of knowledge translation studies focused on paediatric emergency care to describe and assess the interventions used in emergency department settings. METHODS Electronic databases were searched for knowledge translation studies conducted in the emergency department that included the care of children. Two researchers independently reviewed the studies. RESULTS From 1305 publications identified, 15 studies of varied design were included. Four were cluster-controlled trials, two patient-level randomised controlled trials, two interrupted time series, one descriptive study and six before and after intervention studies. Knowledge translation interventions were predominantly aimed at the treating clinician, with some targeting the organisation. Studies assessed effectiveness of interventions over 6-12 months in before and after studies, and 3-28 months in cluster or patient level controlled trials. Changes in clinical practice were variable, with studies on single disease and single treatments in a single site showing greater improvement. CONCLUSIONS Evidence for effective methods to translate knowledge into practice in paediatric emergency medicine is fairly limited. More optimal study designs with more explicit descriptions of interventions are needed to facilitate other groups to effectively apply these procedures in their own setting.
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Affiliation(s)
- Catherine L Wilson
- Departments of Emergency Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - David Johnson
- Departments of Pediatrics and Physiology and Pharmacology, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ed Oakley
- Departments of Emergency Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Zhu B, Li Z, Jiang L, Du B, Jiang Q, Wang M, Lou R, Xi X. Effect of a quality improvement program on weaning from mechanical ventilation: a cluster randomized trial. Intensive Care Med 2015; 41:1781-90. [PMID: 26156108 DOI: 10.1007/s00134-015-3958-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the efficacy of a quality improvement (QI) program for protocol-directed weaning from mechanical ventilation. METHODS This was a prospective, cluster randomized controlled trial. The study consisted of a baseline phase and a QI phase. Fourteen intensive care units (ICUs) in Beijing, China, were randomized into the QI group and non-QI group. The QI group received a QI program to improve the compliance with protocol-directed weaning during the QI phase. RESULTS A total of 444 patients were enrolled in the non-QI group (193 for the baseline, 251 for the QI phase) and 440 in the QI group (199 for the baseline, 241 for the QI phase). During the QI phase in the QI group, compared with the non-QI group, total duration of mechanical ventilation decreased from 7.0 to 3.0 days (p = 0.003), the time before the first weaning attempt decreased from 3.63 to 1.96 days (p = 0.003), length of ICU stay decreased from 10.0 to 6.0 days (p = 0.004), length of hospital stay decreased from 23.0 to 19.0 days (p < 0.001). These differences were also significant in the QI group when the QI phase was compared with the baseline phase. In addition, there was a significant reduction in the percentage of mechanical ventilation exceeding 21 days (p = 0.001) when the baseline phase was compared with the QI phase in the QI group. CONCLUSIONS The QI program involving protocol-directed weaning is associated with beneficial clinical outcomes in mechanically ventilated patients.
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Affiliation(s)
- Bo Zhu
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Zhiqiang Li
- Department of Critical Care Medicine, Hebei United University Affiliated Hospital, Tangshan, China.
| | - Li Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China.
| | - Qi Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Meiping Wang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Ran Lou
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, No. 20 Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
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Dexheimer JW, Borycki EM, Chiu KW, Johnson KB, Aronsky D. A systematic review of the implementation and impact of asthma protocols. BMC Med Inform Decis Mak 2014; 14:82. [PMID: 25204381 PMCID: PMC4174371 DOI: 10.1186/1472-6947-14-82] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation. METHODS PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE. STUDY SELECTION Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor. RESULTS From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay. CONCLUSIONS Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.
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Affiliation(s)
- Judith W Dexheimer
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
| | - Elizabeth M Borycki
- School of Health Information Sciences, University of Victoria, PO Box 3050 STN CSC, Victoria, BC V8W 3P5, Canada
| | - Kou-Wei Chiu
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Kevin B Johnson
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Dominik Aronsky
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
- Department of Emergency Medicine, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
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Britto MT, Vockell ALB, Munafo JK, Schoettker PJ, Wimberg JA, Pruett R, Yi MS, Byczkowski TL. Improving outcomes for underserved adolescents with asthma. Pediatrics 2014; 133:e418-27. [PMID: 24470645 DOI: 10.1542/peds.2013-0684] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting. METHODS Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections. RESULTS Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent's asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels. CONCLUSIONS Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.
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Affiliation(s)
- Maria T Britto
- Division of Adolescent Medicine, Center for Innovation in Chronic Disease Care
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Buyuktiryaki AB, Civelek E, Can D, Orhan F, Aydogan M, Reisli I, Keskin O, Akcay A, Yazicioglu M, Cokugras H, Yuksel H, Zeyrek D, Kocak AK, Sekerel BE. Predicting hospitalization in children with acute asthma. J Emerg Med 2013; 44:919-27. [PMID: 23333182 DOI: 10.1016/j.jemermed.2012.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 05/23/2012] [Accepted: 10/30/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services. OBJECTIVE To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity. METHODS The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours. RESULTS Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577). CONCLUSION Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.
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Affiliation(s)
- A Betul Buyuktiryaki
- Pediatric Allergy and Asthma Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Rosenbluth G, Wilson SD, Maselli JH, Auerbach AD. Analgesic prescribing practices can be improved by low-cost point-of-care decision support. J Pain Symptom Manage 2011; 42:623-31. [PMID: 21458223 PMCID: PMC3139778 DOI: 10.1016/j.jpainsymman.2011.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 01/05/2011] [Accepted: 01/21/2011] [Indexed: 11/16/2022]
Abstract
CONTEXT Codeine has become a controversial choice for analgesia in children compared with other commonly available drugs. OBJECTIVES To evaluate whether an educational campaign shifted resident prescribing patterns away from codeine toward more appropriate analgesics. METHODS Our intervention consisted of a pocket-sized reference card given to all trainees and key staff in an inpatient pediatric acute care unit; pediatrics residents also had the option to attend a one-hour lecture. The pocket card recommended against codeine (including rationale) and gave prescription guidance for our institution's preferred formulary alternative analgesics, which include tramadol and hydrocodone. We used inpatient prescribing data to track the prescribing of codeine and alternative medications over time. RESULTS Following the interventions, there was a significant decrease in the percentage of patients receiving codeine (13.5% of patients received the drug in the year before, 5.4% in the year after, P < 0.0001). Use of hydrocodone-containing analgesics increased overall during the same period (7.4%-16%, P < 0.0001) as did tramadol use (0.2%-2.6%, P < 0.0001). There were no changes in pain management satisfaction scores. CONCLUSION A simple low-cost educational campaign consisting primarily of a pocket guide to analgesics markedly improved analgesic prescribing patterns, and that improvement extended to services not targeted by the didactic component of our educational campaign. Point-of-care decision support by means of a pocket card may be sufficient for effecting change in medication prescribing patterns of trainees.
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Affiliation(s)
- Glenn Rosenbluth
- Division of Pediatric Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA.
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