A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Establishing the Geriatric Emergency Department Intervention in Queensland emergency departments: a qualitative implementation study using the i-PARIHS model

BACKGROUND

Frail older adults require specific, targeted care and expedited shared decision making in the emergency department (ED) to prevent poor outcomes and minimise time spent in this chaotic environment. The Geriatric Emergency Department Intervention (GEDI) model was developed to help limit these undesirable consequences. This qualitative study aimed to explore the ways in which two hospital implementation sites implemented the structures and processes of the GEDI model and to examine the ways in which the i-PARIHS (innovation-Promoting Action on Research Implementation in Health Services) framework influenced the implementation.

METHODS

Using the i-PARIHS approach to implementation, the GEDI model was disseminated into two hospitals using a detailed implementation toolkit, external and internal facilitators and a structured program of support. Following implementation, interviews were conducted with a range of staff involved in the implementation at both sites to explore the implementation process used. Transcribed interviews were analysed for themes and sub-themes.

RESULTS

There were 31 interviews with clinicians involved in the implementation, conducted across two hospitals, including interviews with the two external facilitators. Major themes identified included: (i) elements of the GEDI model adopted or (ii) adapted by implementation sites and (iii) factors that affected the implementation of the GEDI model. Both sites adopted the model of care and there was general support for the GEDI approach to the management of frail older people in the ED. Both sites adapted the structure of the GEDI team and the expertise of the team members to suit their needs and resources. Elements such as service focus, funding, staff development and service evaluation were initially adopted but adaptation occurred over time. Resourcing and cost shifting issues at the implementation sites and at the site providing the external facilitators negatively impacted the facilitation process.

CONCLUSIONS

The i-PARIHS framework provided a pragmatic approach to the implementation of the evidenced-based GEDI model. Passionate, driven clinicians ensured that successful implementation occurred despite unanticipated changes in context at both the implementation and host facilitator sites as well as the absence of sustained facilitation support.

Optimizing Implementation in Cancer Control (OPTICC): protocol for an implementation science center

BACKGROUND

Evidence-based interventions (EBIs) could reduce cervical cancer deaths by 90%, colorectal cancer deaths by 70%, and lung cancer deaths by 95% if widely and effectively implemented in the USA. Yet, EBI implementation, when it occurs, is often suboptimal. This manuscript outlines the protocol for Optimizing Implementation in Cancer Control (OPTICC), a new implementation science center funded as part of the National Cancer Institute Implementation Science Consortium. OPTICC is designed to address three aims. Aim 1 is to develop a research program that supports developing, testing, and refining of innovative, efficient methods for optimizing EBI implementation in cancer control. Aim 2 is to support a diverse implementation laboratory of clinical and community partners to conduct rapid, implementation studies anywhere along the cancer care continuum for a wide range of cancers. Aim 3 is to build implementation science capacity in cancer control by training new investigators, engaging established investigators in cancer-focused implementation science, and contributing to the Implementation Science Consortium in Cancer.

METHODS

Three cores serve as OPTICC's foundation. The Administrative Core plans coordinates and evaluates the Center's activities and leads its capacity-building efforts. The Implementation Laboratory Core (I-Lab) coordinates a network of diverse clinical and community sites, wherein studies are conducted to optimize EBI implementation, implement cancer control EBIs, and shape the Center's agenda. The Research Program Core conducts innovative implementation studies, measurement and methods studies, and pilot studies that advance the Center's theme. A three-stage approach to optimizing EBI implementation is taken-(I) identify and prioritize determinants, (II) match strategies, and (III) optimize strategies-that is informed by a transdisciplinary team of experts leveraging multiphase optimization strategies and criteria, user-centered design, and agile science.

DISCUSSION

OPTICC will develop, test, and refine efficient and economical methods for optimizing EBI implementation by building implementation science capacity in cancer researchers through applications with our I-Lab partners. Once refined, OPTICC will disseminate its methods as toolkits accompanied by massive open online courses, and an interactive website, the latter of which seeks to simultaneously accumulate knowledge across OPTICC studies.

Harnessing implementation science to optimize harm prevention in critically ill children: A pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit

OBJECTIVE

Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses.

METHODS

Single-center cross-sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance.

RESULTS

We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. Seventy-five percent reported being highly impacted by physician attitude toward the CLABSI bundle (motivation).

CONCLUSIONS

PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.

Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study

Background

Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care.

Objective

This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards.

Methods

This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T₀), immediately after the 6-month implementation period (T₁), and again after a 6-month maintenance period (T₂). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined.

Results

This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T₀) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T₁).

Conclusions

Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package.

International Registered Report Identifier (IRRID)

DERR1-10.2196/22902

Moving beyond hand hygiene monitoring as a marker of infection prevention performance: Development of a tailored infection control continuous quality improvement tool

BACKGROUND

Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool.

METHODS

The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery.

RESULTS

Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system.

CONCLUSIONS

Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.

Likelihood of Infectious Outcomes Following Infectious Risk Moments During Patient Care-An International Expert Consensus Study and Quantitative Risk Index

OBJECTIVE To elicit expert consensus on the likelihood of infectious outcomes (patient colonization or infection) following a broad range of infectious risk moments (IRMs) from observations in acute care. DESIGN Expert consensus study using modified Delphi technique. PARTICIPANTS Panel of 40 international experts including nurses, physicians and microbiologists specialized in infectious diseases and infection prevention and control (IPC). METHODS The modified Delphi process consisted of 3 online survey rounds, with feedback of mean ratings and expert comments between rounds. The Delphi survey comprised 52 care scenarios representing observed IRMs organized into 6 sections: hands, gloves, medical devices, mobile objects, invasive procedures, and additional moments. For each scenario, experts indicated the likelihood of both patient colonization and infection on a scale from 0 to 5 (high). Expert ratings were plotted against frequencies of IRMs observed during actual patient care resulting in a risk index. RESULTS Following 3 rounds, consensus was achieved for 92 of 104 items (88.5%). The mean ratings across all scenarios for likelihood of colonization and infection were 2.68 and 2.02, respectively. The likelihood of colonization was rated higher than infection for 48 of 52 scenarios. Ratings were significantly higher for colonization (P=.001) and infection (P<.0005) when the scenario involved transfer of pathogens to critical patient sites. CONCLUSIONS The design of effective IPC strategies requires the selection of behaviors according to their impact on patient outcomes. The IRM index reported here provides a basis for standardizing and prioritizing targets for quality improvement initiatives, training, and future research in acute health care. Infect Control Hosp Epidemiol 2018;39:280-289.

Guideline implementation for the treatment of undescended testes: Still room for improvement

BACKGROUND

Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery.

METHODS

In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) <12 months, (2) 12-24 months, (3) >24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings.

RESULTS

Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0-196], median age at surgery was 15 months [range 0-202].

CONCLUSION

Delayed referral is the main reason for guideline non-conform delayed surgery in UDT.

TYPE OF STUDY

Clinical Research paper.

LEVEL OF EVIDENCE

Level III: Treatment Study.

How do clinicians use implementation tools to apply breast cancer screening guidelines to practice?

Background

Implementation tools (iTools) may enhance uptake of guidelines. However, little evidence exists on their use by primary care clinicians. This study explored which iTools clinicians used and how often; how satisfied clinicians were with the tools; whether tool use was associated with practice changes; and identified mediators for practice change(s) related to breast cancer screening (BCS).

Methods

Canadian primary care providers who are members of the Practice-Based Small Group Learning Program (n = 1464) were invited to participate in this mixed methods study. An educational module was discussed in a small group learning context, and data collection included an on-line survey, practice reflection tools (PRTs), and interviews. The module included both the Canadian Task Force on Preventive Health Care revised guideline on BCS and iTools for clinician and/or patient use. After discussing the module and at 3 months, participants completed PRTs identifying their planned practice change(s) and documenting implementation outcome(s). Use of the iTools was explored via online survey and individual interviews.

Results

Seventy participants agreed to participate. Of these, 48 participated in the online survey, 43 completed PRTs and 14 were interviewed. Most survey participants (77%) reported using at least one of seven tools available for implementing BCS guideline. Of these (78%) reported using more than one tool. Almost all participants used tools for clinicians (92%) and 62% also used tools for patients. As more tools were used, more practice changes were reported on the survey and PRTs. Interviews provided additional findings. Once information from an iTool was internalized, there was no further need for the tool. Participants did not use tools (23%) due to disagreements with the BCS guideline, patients’ expectations, and/or experiences with diagnosis of breast cancer.

Conclusion

This study found that clinicians use tools to implement practice changes related to BCS guideline. Tools developed for clinicians were used to understand and consolidate the recommendations before tools to be used with patients were employed to promote decision-making. Mediating factors that impacted tool use confirmed previous research. Finally, use of some iTools decreased over time because information was internalized.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0765-2) contains supplementary material, which is available to authorized users.

The development of hand hygiene compliance imperatives in an emergency department

BACKGROUND

Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance.

PURPOSE

To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department.

METHODS

A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed.

RESULTS

Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff. Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work.

CONCLUSIONS

The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations.

Analysis of the barriers and enablers to implementing lifestyle management practices for women with PCOS in Singapore

BACKGROUND

Polycystic ovary syndrome (PCOS) is a condition that affects women of reproductive age and manifests with adverse reproductive, metabolic and psychological consequences. Evidence-based PCOS guidelines recommend lifestyle management first line for infertility. In Singapore women with PCOS can attend the PCOS Clinic at the Kandang Kerbau Women and Children's Hospital for infertility treatment. However lifestyle integration into infertility management is currently limited and barriers and enablers to progress remain unclear.

METHODS

All PCOS clinic staff undertook semi-structured interviews to investigate perceived barriers for staff and consumers for the integration of lifestyle into infertility management. This study utilised various tools including an 8P Ishikawa diagram model to identify and categorise barriers. A modified Hanlon method was then used to prioritise barriers within the Singaporean context considering organisational, cultural and financial constraints. Propriety, economics, acceptability, resources and legality (PEARL) criteria were also incorporated into this decision-making tool.

RESULTS

In the 8P model, there were five factors contributing to the 'procedure (consultations and referral processes)' barrier, one 'policy (government and hospitals)' factor, five 'place' factors, two 'product (lifestyle management programme)' barriers, two 'people (programme capacity)' factors, four 'process (integration)' factors, three 'promotion' barriers and three 'price' factors. Of the prioritised barriers, two were identified across each of 'procedures', 'place', 'product' and 'people' and four related to 'processes'. There were no barriers identified that for 'policies', 'promotion' and 'price' that can be addressed.

CONCLUSIONS

There is a clear need to integrate lifestyle into infertility management in PCOS, in line with current national and international evidence-based guidelines. The highest priority identified improvement opportunity was to develop a collaborative lifestyle management programme across hospital services. Reductions in variation of delivery and strengthening support within the lifestyle programme are other identified priorities. The strength of this study is that this is the first study to utilise a pragmatic quality improvement method for barriers identification and prioritisation in the area of lifestyle management for women with PCOS. This project identified factors that may provide easy improvements, but also identified some local factors that may be very difficult to change. The major limitation of this study is that it is only looking at the Singapore setting, so may have limited applicability to other countries. However, results from quality improvement projects are meant to be context specific.

Eliminating Central Line–Associated Bloodstream Infections: A National Patient Safety Imperative

Background.

Several studies demonstrating that central line–associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

Methods.

We conducted a collaborative cohort study to evaluate the impact of the national “On the CUSP: Stop BSI” program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.

Results.

A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16–18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50–0.65) at 16–18 months after implementation.

Conclusion.

Coincident with the implementation of the national “On the CUSP: Stop BSI” program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Tailoring interventions to implement recommendations for the treatment of elderly patients with depression: a qualitative study

BACKGROUND

To improve adherence to evidence-based recommendations, it is logical to identify determinants of practice and tailor interventions to address these. We have previously prioritised six recommendations to improve treatment of elderly patients with depression, and identified determinants of adherence to these recommendations. The aim of this article is to describe how we tailored interventions to address the determinants for the implementation of the recommendations.

METHODS

We drafted an intervention plan, based on the determinants we had identified in a previous study. We conducted six group interviews with representatives of health professionals (GPs and nurses), implementation researchers, quality improvement officers, professional and voluntary organisations and relatives of elderly patients with depression. We informed about the gap between evidence and practice for elderly patients with depression and presented the prioritised determinants that applied to each recommendation. Participants brainstormed individually and then in groups, suggesting interventions to address the determinants. We then presented evidence on the effectiveness of strategies for implementing depression guidelines. We asked the groups to prioritise the suggested interventions considering the perceived impact of determinants and of interventions, the research evidence underlying the interventions, feasibility and cost. We audiotaped and transcribed the interviews and applied a five step framework for our analysis. We created a logic model with links between the determinants, the interventions, and the targeted improvements in adherence.

RESULTS

Six groups with 29 individuals provided 379 suggestions for interventions. Most suggestions could be fit within the drafted plan, but the groups provided important amendments or additions. We sorted the interventions into six categories: resources for municipalities to develop a collaborative care plan, resources for health professionals, resources for patients and their relatives, outreach visits, educational and web-based tools. Some interventions addressed one determinant, while other interventions addressed several determinants.

CONCLUSIONS

It was feasible and helpful to use group interviews and combine open and structured approaches to identify interventions that addressed prioritised determinants to adherence to the recommendations. This approach generated a large number of suggested interventions. We had to prioritise to tailor the interventions strategies.

ICU director data: using data to assess value, inform local change, and relate to the external world

Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. In this review, we provide a conceptual framework for understanding value metrics, describe an approach to developing a value measurement program, and summarize common metrics to characterize ICU value. We first summarize how ICU value can be represented as a function of outcomes and costs. We expand this equation and relate it to both the classic structure-process-outcome framework for quality assessment and the Institute of Medicine's six aims of health care. We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients.

Medical Physics Practice Guideline 4.a: Development, implementation, use and maintenance of safety checklists

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.

The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.

Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.

The following terms are used in the AAPM practice guidelines:

Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.

Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Implementing a Multifaceted Intervention to Decrease Central Line–Associated Bloodstream Infections in SEHA (Abu Dhabi Health Services Company) Intensive Care Units: The Abu Dhabi Experience

OBJECTIVE

To determine whether implementation of a multifaceted intervention would significantly reduce the incidence of central line–associated bloodstream infections.

DESIGN

Prospective cohort collaborative.

SETTING AND PARTICIPANTS

Intensive care units of the Abu Dhabi Health Services Company hospitals in the Emirate of Abu Dhabi.

INTERVENTIONS

A bundled intervention consisting of 3 components was implemented as part of the program. It consisted of a multifaceted approach that targeted clinician use of evidence-based infection prevention recommendations, tools that supported the identification of local barriers to these practices, and implementation ideas to help ensure patients received the practices. Comprehensive unit-based safety teams were created to improve safety culture and teamwork. Finally, the measurement and feedback of monthly infection rate data to safety teams, senior leaders, and staff in participating intensive care units was encouraged. The main outcome measure was the quarterly rate of central line–associated bloodstream infections.

RESULTS

Eighteen intensive care units from 7 hospitals in Abu Dhabi implemented the program and achieved an overall 38% reduction in their central line–associated bloodstream infection rate, adjusted at the hospital and unit level. The number of units with a quarterly central line–associated bloodstream infection rate of less than 1 infection per 1,000 catheter-days increased by almost 40% between the baseline and postintervention periods.

CONCLUSION

A significant reduction in the global morbidity and mortality associated with central line–associated bloodstream infections is possible across intensive care units in disparate settings using a multifaceted intervention.

Infect. Control Hosp. Epidemiol. 2015;36(7):816–822

Infectious risk moments: a novel, human factors-informed approach to infection prevention

We pilot tested a novel human factors-informed concept to identify infectious risk moments (IRMs) that occur with high frequency during routine intensive care. Following 30 observation-hours, 28 potential IRMs related to hand hygiene, gloves, and objects were expert rated. A comprehensive IRM inventory may provide valuable taxonomy for research, training, and intervention.

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice

BACKGROUND

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.

STUDY DESIGN AND METHODS

A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.

RESULTS

Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.

CONCLUSIONS

Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study

Introduction

Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. However, there is inadequate data to inform the optimal method or level of tailoring. Consequently, we conducted the PERFormance Enhancement of the Canadian nutrition guidelines by a Tailored Implementation Strategy (PERFECTIS) study to determine the feasibility of a multifaceted, interdisciplinary, tailored intervention aimed at improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Methods

A before-after study was conducted in seven ICUs from five hospitals in North America. During a 3-month pre-implementation phase, each ICU completed a nutrition practice audit to identify guideline-practice gaps and a barriers assessment to identify obstacles to practice change. During a one day meeting, the results of the audit and barriers assessment were reviewed and used to develop a site-specific tailored action plan. The tailored action plan was then implemented over a 12-month period that included bi-monthly progress meetings. Compliance with the tailored action plan was determined by the proportion of items in the action plan that was completely implemented. We examined acceptability of the intervention through staff responses to an evaluation questionnaire. In addition, the nutrition practice audit and barriers survey were repeated at the end of the implementation phase to determine changes in barriers and nutrition practices.

Results

All five sites successfully completed all aspects of the study. However, their ability to fully implement all of their developed action plans varied from 14% to 75% compliance. Nurses, on average, rated the study-related activities and resources as ‘somewhat useful’ and a third of respondents ‘agreed’ or ‘strongly agreed’ that their nutrition practice had changed as a result of the intervention. We observed a statistically significant 10% (Site range -4.3% to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5% to 17.9%) and 4% (-8.3% to 18.2%) increase in the adequacy of total nutrition from calories and protein, respectively.

Conclusions

The multifaceted tailored intervention appears to be feasible but further refinement is warranted prior to testing the effectiveness of the approach on a larger scale.

Trial registration

ClinicalTrials.gov NCT01168128. Registered 21 July 2010.

RBC transfusion practices among critically ill patients: has evidence changed practice?

OBJECTIVE

Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort.

DESIGN

Retrospective population-based cohort study.

SETTING

Thirty-five Maryland hospitals.

PATIENTS

Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994-1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999-2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging>200 annual ICU discharges and hospitals averaging≤200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01-1.13] annually and 1.03 [95% CI, 0.99-1.07] annually, respectively; p=0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93-0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08-1.13] annually), p<0.001.

CONCLUSIONS

In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.

Effect of a pleural checklist on patient safety in the ultrasound era

BACKGROUND AND OBJECTIVE

Bedside ultrasound allows direct visualization of pleural collections for thoracentesis and tube thoracostomy. However, there is little information on patient safety improvement methods with this approach. The effect of a checklist on patient safety for bedside ultrasound-guided pleural procedures was evaluated.

METHODS

A prospective study of ultrasound-guided pleural procedures from September 2007 to June 2010 was performed. Ultrasound guidance was routine practice for all patients under the institution's care and the freehand method was used. All operators took a half-day training session on basic thoracic ultrasound and were supervised by more experienced operators. A 14-item checklist was introduced in June 2009. It included systematic thoracic scanning and a safety audit. Clinical and safety data are described before (Phase I) and after (Phase II) the introduction of the checklist.

RESULTS

There were 121 patients in Phase I (58.7 ± 18.9 years) and 134 patients in Phase II (60.2 ± 19.6 years). Complications occurred for 10 patients (8.3%) in Phase I (six dry taps, three pneumothoraces, one haemothorax) and for 2 patients (1.5%) in Phase II (one significant bleed, one malposition of chest tube) (P = 0.015). There were no procedure-related deaths. The use of the checklist alone was associated with fewer procedure-related complications. This was independent of thoracostomy rate, pleural effusion size and pleural fluid ultrasound appearance.

CONCLUSIONS

A pleural checklist with systematic scanning and close supervision may further enhance safety of ultrasound-guided procedures. This may also help promote safety while trainees are learning to perform these procedures.

Rural, suburban, and urban differences in factors that impact physician adherence to clinical preventive service guidelines

PURPOSE

Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians.

METHODS

This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts.

FINDINGS

Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians.

CONCLUSIONS

The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice

Background

Determinants of practice are factors that might prevent or enable improvements. Several checklists, frameworks, taxonomies, and classifications of determinants of healthcare professional practice have been published. In this paper, we describe the development of a comprehensive, integrated checklist of determinants of practice (the TICD checklist).

Methods

We performed a systematic review of frameworks of determinants of practice followed by a consensus process. We searched electronic databases and screened the reference lists of key background documents. Two authors independently assessed titles and abstracts, and potentially relevant full text articles. We compiled a list of attributes that a checklist should have: comprehensiveness, relevance, applicability, simplicity, logic, clarity, usability, suitability, and usefulness. We assessed included articles using these criteria and collected information about the theory, model, or logic underlying how the factors (determinants) were selected, described, and grouped, the strengths and weaknesses of the checklist, and the determinants and the domains in each checklist. We drafted a preliminary checklist based on an aggregated list of determinants from the included checklists, and finalized the checklist by a consensus process among implementation researchers.

Results

We screened 5,778 titles and abstracts and retrieved 87 potentially relevant papers in full text. Several of these papers had references to papers that we also retrieved in full text. We also checked potentially relevant papers we had on file that were not retrieved by the searches. We included 12 checklists. None of these were completely comprehensive when compared to the aggregated list of determinants and domains. We developed a checklist with 57 potential determinants of practice grouped in seven domains: guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organisational change, and social, political, and legal factors. We also developed five worksheets to facilitate the use of the checklist.

Conclusions

Based on a systematic review and a consensus process we developed a checklist that aims to be comprehensive and to build on the strengths of each of the 12 included checklists. The checklist is accompanied with five worksheets to facilitate its use in implementation research and quality improvement projects.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Nursing leadership at the crossroads: evidence-based practice 'Matching Michigan-minimizing catheter related blood stream infections'(*)

AIMS AND OBJECTIVES

a highly successful intervention to reduce infections in intensive care units (ICUs) is now being widely replicated and involved significant nursing leadership. The objective of this manuscript is to describe briefly the intervention, and more explicitly the implications for nursing leadership as quality improvement and patient safety become global healthcare priorities.

DESIGN

collaborative cohort study in over 100 ICUs in the United States to implement and evaluate interventions to improve patients' safety.

METHODS

conceptual model aimed at improving clinicians' use of five evidence-based recommendations to reduce rates of catheter-related bloodstream infections rates, with measurement and feedback of infection rates.

RESULTS

one hundred and three ICUs contributed 1981 ICU-months of data representing 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P ≤ 0·002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16-18 months of follow-up (P < 0·002). During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month postimplementation period (-1%, 95% confidence interval -9% to 7%). Eighty seven percent of the original study participants had data available for the sustainability study.

CONCLUSIONS

broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter-related bloodstream infections.

RELEVANCE TO CLINICAL PRACTICE

the initial Michigan study and the follow-up analysis, that demonstrated sustained improvements, are leading to similar projects in other countries, include the Matching Michigan project in England. Discussing not only the technical components of the program, but also the nursing leadership aspects may assist nurses just embarking on this work.

A research framework for reducing preventable patient harm

Programs to reduce central line-associated bloodstream infections (CLABSIs) have improved the safety of hospitalized patients. Efforts are underway to disseminate these successes broadly to reduce other types of hospital-acquired infectious and noninfectious preventable harms. Unfortunately, the ability to broadly measure and prevent other types of preventable harms, especially infectious harms, needs enhancement. Moreover, an overarching research framework for creating and integrating evidence will help expedite the development of national prevention programs. This article outlines a 5-phase translational (T) framework to develop robust research programs that reduce preventable harm, as follows: phase T0, discover opportunities and approaches to prevent adverse health care events; phase T1, use T0 discoveries to develop and test interventions on a small scale; phase T2, broaden and strengthen the evidence base for promising interventions to develop evidence-based guidelines; phase T3, translate guidelines into clinical practice; and phase T4, implement and evaluate T3 work on a national and international scale. Policy makers should use this framework to fill in the knowledge gaps, coordinate efforts among federal agencies, and prioritize research funding.

American Academy of Dermatology evidence-based guideline development process: responding to new challenges and establishing transparency

BACKGROUND

Evidence-based clinical guidelines are developed to educate and inform physicians about best practices in patient care, and assist providers in the application of treatments and technologies that can improve outcomes. Clinical guidelines also aid appeal of payment decisions; serve as the basis for quality measure development, appropriateness criteria, and maintenance of certification modules; and help identify areas for further clinical research.

OBJECTIVE

For guidelines to serve dermatologists effectively in these diverse roles, they must be current, varied in clinical focus, and developed with a high degree of rigor that includes attention to potential conflicts of interest.

METHOD

To address these needs and keep pace with advances in medicine, the American Academy of Dermatology (AAD) recently revised the evidence-based guideline development process.

RESULTS

Key changes include development of a yearly needs assessment process to determine what guidelines are most needed, the development of focused guidelines that address rapidly evolving clinical topics, a formal method of vetting guidelines produced by other societies, and a scheduled reassessment of existing guidelines to ensure they provide current and practical information. The process for identifying and managing potential conflicts of interest was also revised and expanded to meet current expectations and evolving standards.

LIMITATIONS

The impact of these changes to the AAD's guideline development process will not be fully realized for several years.

CONCLUSIONS

These changes will help ensure the AAD will be able to provide its members with continued evidence-based guidance to support patient care across the scope of dermatologic practice.

A disciplined approach to implementation of evidence-based practices decreases ICU and hospital length of stay in traumatically injured patients

BACKGROUND

Evidence-based medicine has gained wide acceptance in practice of medicine since the 1990s. The objective of our study was to demonstrate the effect of evidence-based critical care practices on ICU and hospital length of stay in mechanically ventilated trauma patients.

MATERIALS AND METHODS

Retrospective cohort using historic controls. During 2004, several different evidence-based practices were implemented, including low tidal volume ventilation, protocol driven trauma resuscitation, and a sepsis bundle. Outcomes in critically ill, mechanically ventilated patients who were ≥ 18 y old were compared between a historic control group (2000-2003) and the study group after implementation (2005-2008). Patients were identified using the institutional trauma registry (NATIONAL TRACS). Gender, age, ISS, mechanism of injury, and mortality were also examined to identify trends in epidemiology.

RESULTS

From 2000 to 2003. there were 6920 trauma admissions and during 2005-2008 there were 8911 (increase of 28.8%). These included 217 and 337 (increase of 55.3%) admissions to the ICU of mechanically ventilated patients, respectively. The mean age was 43.9 y versus 45.9 y (P = 0.258). Males were 66.4% versus 71.8% (P = 0.610). The mean ISS was 29 versus 27 (P = 0.25). Blunt mechanism was 87% versus 89% (P = 0.913). Mortality rate was 36.4% versus 36.5% (P = 0.944). The mean number of ICU days and hospital days decreased from 7.6 versus 5.5 (P = 0.02) and 13.2 versus 9.7 (P = 0.03), respectively.

CONCLUSION

The application of evidence-based critical care practices decreases length of ICU and hospital stay, but not mortality, in critically ill, mechanically ventilated trauma patients. Our trauma volume, including critically ill patients, increased during the study periods.