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Ackerhans S, Huynh T, Kaiser C, Schultz C. Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review. Implement Sci 2024; 19:11. [PMID: 38347525 PMCID: PMC10860285 DOI: 10.1186/s13012-024-01339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity. METHODS We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists). RESULTS One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation. CONCLUSION This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.
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Affiliation(s)
- Sophia Ackerhans
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany.
| | - Thomas Huynh
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Kaiser
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Schultz
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
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Li T, Wu B, Li L, Bian A, Ni J, Liu K, Qin Z, Peng Y, Shen Y, Lv M, Lu X, Xing C, Mao H. Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2351710. [PMID: 38241047 PMCID: PMC10799260 DOI: 10.1001/jamanetworkopen.2023.51710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024] Open
Abstract
Importance Despite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients. Objective To evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI. Design, Setting, and Participants This single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population. Interventions A programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures. Main Outcomes and Measures The primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI. Results A total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (-6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (-9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P < .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P < .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P < .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups. Conclusions and Relevance Results of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice. Trial Registration ClinicalTrials.gov Identifier: NCT03736304.
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Affiliation(s)
- Ting Li
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Buyun Wu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Li
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ao Bian
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Ni
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kang Liu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongke Qin
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yudie Peng
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yining Shen
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mengru Lv
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyi Lu
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Lambert SI, Madi M, Sopka S, Lenes A, Stange H, Buszello CP, Stephan A. An integrative review on the acceptance of artificial intelligence among healthcare professionals in hospitals. NPJ Digit Med 2023; 6:111. [PMID: 37301946 DOI: 10.1038/s41746-023-00852-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Artificial intelligence (AI) in the domain of healthcare is increasing in prominence. Acceptance is an indispensable prerequisite for the widespread implementation of AI. The aim of this integrative review is to explore barriers and facilitators influencing healthcare professionals' acceptance of AI in the hospital setting. Forty-two articles met the inclusion criteria for this review. Pertinent elements to the study such as the type of AI, factors influencing acceptance, and the participants' profession were extracted from the included studies, and the studies were appraised for their quality. The data extraction and results were presented according to the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The included studies revealed a variety of facilitating and hindering factors for AI acceptance in the hospital setting. Clinical decision support systems (CDSS) were the AI form included in most studies (n = 21). Heterogeneous results with regard to the perceptions of the effects of AI on error occurrence, alert sensitivity and timely resources were reported. In contrast, fear of a loss of (professional) autonomy and difficulties in integrating AI into clinical workflows were unanimously reported to be hindering factors. On the other hand, training for the use of AI facilitated acceptance. Heterogeneous results may be explained by differences in the application and functioning of the different AI systems as well as inter-professional and interdisciplinary disparities. To conclude, in order to facilitate acceptance of AI among healthcare professionals it is advisable to integrate end-users in the early stages of AI development as well as to offer needs-adjusted training for the use of AI in healthcare and providing adequate infrastructure.
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Affiliation(s)
- Sophie Isabelle Lambert
- AIXTRA-Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Anesthesiology, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Murielle Madi
- Department of Nursing Science, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Saša Sopka
- AIXTRA-Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
- Department of Anesthesiology, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andrea Lenes
- AIXTRA-Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Hendrik Stange
- Fraunhofer Society for the Advancement of Applied Research. Fraunhofer-Institute for Intelligent Analysis and Information Systems IAIS, Schloss Birlinghoven 1, 53757, Sankt Augustin, Bonn, Germany
| | - Claus-Peter Buszello
- Fraunhofer Society for the Advancement of Applied Research. Fraunhofer-Institute for Intelligent Analysis and Information Systems IAIS, Schloss Birlinghoven 1, 53757, Sankt Augustin, Bonn, Germany
| | - Astrid Stephan
- Department of Nursing Science, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
- Fliedner University of Applied Sciences, Geschwister-Aufricht-Straße, 940489, Düsseldorf, Germany
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Hammouda N, Neyra JA. Can Artificial Intelligence Assist in Delivering Continuous Renal Replacement Therapy? Adv Chronic Kidney Dis 2022; 29:439-449. [PMID: 36253027 PMCID: PMC9586461 DOI: 10.1053/j.ackd.2022.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
Continuous renal replacement therapy (CRRT) is widely utilized to support critically ill patients with acute kidney injury. Artificial intelligence (AI) has the potential to enhance CRRT delivery, but evidence is limited. We reviewed existing literature on the utilization of AI in CRRT with the objective of identifying current gaps in evidence and research considerations. We conducted a scoping review focusing on the development or use of AI-based tools in patients receiving CRRT. Ten papers were identified; 6 of 10 (60%) published in 2021, and 6 of 10 (60%) focused on machine learning models to augment CRRT delivery. All innovations were in the design/early validation phase of development. Primary research interests focused on early indicators of CRRT need, prognostication of mortality and kidney recovery, and identification of risk factors for mortality. Secondary research priorities included dynamic CRRT monitoring, predicting CRRT-related complications, and automated data pooling for point-of-care analysis. Literature gaps included prospective validation and implementation, biases ascertainment, and evaluation of AI-generated health care disparities. Research on AI applications to enhance CRRT delivery has grown exponentially in the last years, but the field remains premature. There is a need to evaluate how these applications could enhance bedside decision-making capacity and assist structure and processes of CRRT delivery.
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Affiliation(s)
- Nada Hammouda
- Department of Applied Clinical Research, University of Texas, Southwestern, Dallas, TX
| | - Javier A Neyra
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
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McIlmurray L, Blackwood B, Dempster M, Kee F, Gillan C, Hagan R, Lohfeld L, Shyamsundar M. Electronic nudge tool technology used in the critical care and peri-anaesthetic setting: a scoping review protocol. BMJ Open 2022; 12:e057026. [PMID: 35820751 PMCID: PMC9277380 DOI: 10.1136/bmjopen-2021-057026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Electronic clinical decision support (eCDS) tools are used to assist clinical decision making. Using computer-generated algorithms with evidence-based rule sets, they alert clinicians to events that require attention. eCDS tools generating alerts using nudge principles present clinicians with evidence-based clinical treatment options to guide clinician behaviour without restricting freedom of choice. Although eCDS tools have shown beneficial outcomes, challenges exist with regard to their acceptability most likely related to implementation. Furthermore, the pace of progress in this field has allowed little time to effectively evaluate the experience of the intended user. This scoping review aims to examine the development and implementation strategies, and the impact on the end user of eCDS tools that generate alerts using nudge principles, specifically in the critical care and peri-anaesthetic setting. METHODS AND ANALYSIS This review will follow the Arksey and O'Malley framework. A search will be conducted of literature published in the last 15 years in MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science and SAGE databases. Citation screening and data extraction will be performed by two independent reviewers. Extracted data will include context, e-nudge tool type and design features, development, implementation strategies and associated impact on end users. ETHICS AND DISSEMINATION This scoping review will synthesise published literature therefore ethical approval is not required. Review findings will be published in topic relevant peer-reviewed journals and associated conferences.
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Affiliation(s)
- Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Martin Dempster
- Centre for Improving Health-Related Quality of Life (CIHRQoL) - School of Psychology, Queen's University Belfast, Belfast, UK
| | - Frank Kee
- UKCRC Centre of Excellence for Public Health (NI), Queen's University Belfast, Belfast, UK
| | - Charles Gillan
- School of Electronics, Electrical Engineering and Computer Science, Queen's University Belfast, Belfast, UK
| | - Rachael Hagan
- School of Electronics, Electrical Engineering and Computer Science, Queen's University Belfast, Belfast, UK
| | - Lynne Lohfeld
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Ridgway JP, Robicsek A, Shah N, Smith BA, Singh K, Semel J, Acree ME, Grant J, Ravichandran U, Peterson LR. A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship. Clin Infect Dis 2021; 72:e265-e271. [PMID: 32712674 DOI: 10.1093/cid/ciaa1048] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). METHODS We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. RESULTS In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). CONCLUSIONS Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.
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Affiliation(s)
- Jessica P Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ari Robicsek
- Providence St. Joseph Health, Seattle, Washington, USA
| | - Nirav Shah
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Becky A Smith
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kamaljit Singh
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jeffery Semel
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Jennifer Grant
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Lance R Peterson
- Pritzer School of Medicine, University of Chicago, Chicago, Illinois, USA
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Bailey S, Hunt C, Brisley A, Howard S, Sykes L, Blakeman T. Implementation of clinical decision support to manage acute kidney injury in secondary care: an ethnographic study. BMJ Qual Saf 2020; 29:382-389. [PMID: 31796574 PMCID: PMC7241968 DOI: 10.1136/bmjqs-2019-009932] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Over the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care. METHODS An ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption. RESULTS The two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice. CONCLUSIONS Our analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.
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Affiliation(s)
- Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | - Carianne Hunt
- Liverpool Health Partners, University of Liverpool, Liverpool, Merseyside, UK
| | - Adam Brisley
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Susan Howard
- Emergency Admissions Unit, Salford Royal Hospitals NHS Trust, Salford, Salford, UK
| | - Lynne Sykes
- Emergency Admissions Unit, Salford Royal Hospitals NHS Trust, Salford, Salford, UK
| | - Thomas Blakeman
- Centre for Primary Care, University of Manchester, Manchester, UK
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Krawiec C, Gerard S, Iriana S, Berger R, Levi B. What We Can Learn From Failure: An EHR-Based Child Protection Alert System. CHILD MALTREATMENT 2020; 25:61-69. [PMID: 31137955 DOI: 10.1177/1077559519848845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This study aimed to evaluate the efficacy of a newly implemented Child Protection Alert System (CPAS) that utilizes triggering diagnoses to identify children who have been confirmed/strongly suspected as maltreated. We retrospectively reviewed electronic health records (EHRs) of 666 patients evaluated by our institution's child protection team between 2009 and 2014. We examined each EHR for the presence of a pop-up alert, a persistent text-based visual alert, and diagnoses denoting child maltreatment. Diagnostic accuracy of the CPAS for child maltreatment identification was assessed. Of 323 patients for whom child maltreatment was confirmed/strongly suspected, 21.7% (70/323) had a qualifying longitudinal diagnosis listed. The pop-up alert fired in 14% of cases (45/323) with a sensitivity and specificity of 13.9% (95% CI [10.4%, 18.2%]) and 100% (95% CI [98.9%, 100.0%]), respectively. The text-based visual alert displayed in 44 of 45 cases. The CPAS is a novel simple way to support clinical decision-making to identify and protect children at risk of (re)abuse. This study highlights multiple barriers that must be overcome to effectively design and implement a CPAS to protect at-risk children.
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Affiliation(s)
- Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Children's Hospital, Hershey, PA, USA
| | - Seth Gerard
- Emergency Medicine, York Hospital, York, PA, USA
| | - Sarah Iriana
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Rachel Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin Levi
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
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Scott J, Finch T, Bevan M, Maniatopoulos G, Gibbins C, Yates B, Kilimangalam N, Sheerin N, Kanagasundaram NS. Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England. BMJ Open 2019; 9:e032925. [PMID: 31831546 PMCID: PMC6924771 DOI: 10.1136/bmjopen-2019-032925] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Around one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care. DESIGN Mixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods. SETTING AND PARTICIPANTS Three secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101). ANALYSIS Qualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation. RESULTS Participants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation). CONCLUSIONS Clinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.
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Affiliation(s)
- Jason Scott
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Tracy Finch
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Mark Bevan
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | | | - Chris Gibbins
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bryan Yates
- Northumbria Healthcare NHS Foundation Trust, North Shields, Tyne and Wear, UK
| | | | - Neil Sheerin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Nigel Suren Kanagasundaram
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review. Br J Gen Pract 2019; 69:e809-e818. [PMID: 31740460 DOI: 10.3399/bjgp19x706745] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/26/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The diagnosis of cancer in primary care is complex and challenging. Electronic clinical decision support tools (eCDSTs) have been proposed as an approach to improve GP decision making, but no systematic review has examined their role in cancer diagnosis. AIM To investigate whether eCDSTs improve diagnostic decision making for cancer in primary care and to determine which elements influence successful implementation. DESIGN AND SETTING A systematic review of relevant studies conducted worldwide and published in English between 1 January 1998 and 31 December 2018. METHOD Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a consultation of reference lists and citation tracking was carried out. Exclusion criteria included the absence of eCDSTs used in asymptomatic populations, and studies that did not involve support delivered to the GP. The most relevant Joanna Briggs Institute Critical Appraisal Checklists were applied according to study design of the included paper. RESULTS Of the nine studies included, three showed improvements in decision making for cancer diagnosis, three demonstrated positive effects on secondary clinical or health service outcomes such as prescribing, quality of referrals, or cost-effectiveness, and one study found a reduction in time to cancer diagnosis. Barriers to implementation included trust, the compatibility of eCDST recommendations with the GP's role as a gatekeeper, and impact on workflow. CONCLUSION eCDSTs have the capacity to improve decision making for a cancer diagnosis, but the optimal mode of delivery remains unclear. Although such tools could assist GPs in the future, further well-designed trials of all eCDSTs are needed to determine their cost-effectiveness and the most appropriate implementation methods.
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Mishuris RG, Palmisano J, McCullagh L, Hess R, Feldstein DA, Smith PD, McGinn T, Mann DM. Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings. BMJ Health Care Inform 2019; 26:bmjhci-2019-100088. [PMID: 31630113 PMCID: PMC7062348 DOI: 10.1136/bmjhci-2019-100088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Effective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of 'work' necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and 'work' of implementation of two clinical decision support (CDS) tools across diverse care settings. METHODS We conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions' primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time. RESULTS The median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers' participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008). CONCLUSIONS This study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies. TRIAL REGISTRATION NUMBER NCT02534987.
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Affiliation(s)
| | - Joseph Palmisano
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lauren McCullagh
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Thomas McGinn
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Devin M Mann
- New York University School of Medicine, New York City, New York, USA
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Van Dort BA, Zheng WY, Baysari MT. Prescriber perceptions of medication-related computerized decision support systems in hospitals: A synthesis of qualitative research. Int J Med Inform 2019; 129:285-295. [DOI: 10.1016/j.ijmedinf.2019.06.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/24/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023]
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13
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Connell A, Black G, Montgomery H, Martin P, Nightingale C, King D, Karthikesalingam A, Hughes C, Back T, Ayoub K, Suleyman M, Jones G, Cross J, Stanley S, Emerson M, Merrick C, Rees G, Laing C, Raine R. Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals. J Med Internet Res 2019; 21:e13143. [PMID: 31368443 PMCID: PMC6693304 DOI: 10.2196/13143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/29/2019] [Accepted: 03/24/2019] [Indexed: 01/16/2023] Open
Abstract
Background One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally enabled care pathway for patients with acute kidney injury (AKI) at a tertiary referral hospital in the United Kingdom. A dedicated clinical response team—comprising existing nephrology and patient-at-risk and resuscitation teams—received AKI alerts in real time via Streams, a mobile app. Here, we present a qualitative evaluation of the experiences of users and other health care professionals whose work was affected by the implementation of the care pathway. Objective The aim of this study was to qualitatively evaluate the impact of mobile results viewing and automated alerting as part of a digitally enabled care pathway on the working practices of users and their interprofessional relationships. Methods A total of 19 semistructured interviews were conducted with members of the AKI response team and clinicians with whom they interacted across the hospital. Interviews were analyzed using inductive and deductive thematic analysis. Results The digitally enabled care pathway improved access to patient information and expedited early specialist care. Opportunities were identified for more constructive planning of end-of-life care due to the earlier detection and alerting of deterioration. However, the shift toward early detection also highlighted resource constraints and some clinical uncertainty about the value of intervening at this stage. The real-time availability of information altered communication flows within and between clinical teams and across professional groups. Conclusions Digital technologies allow early detection of adverse events and of patients at risk of deterioration, with the potential to improve outcomes. They may also increase the efficiency of health care professionals’ working practices. However, when planning and implementing digital information innovations in health care, the following factors should also be considered: the provision of clinical training to effectively manage early detection, resources to cope with additional workload, support to manage perceived information overload, and the optimization of algorithms to minimize unnecessary alerts.
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Affiliation(s)
- Alistair Connell
- Centre for Human Health and Performance, University College London, London, United Kingdom.,DeepMind Health, London, United Kingdom
| | - Georgia Black
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Hugh Montgomery
- Centre for Human Health and Performance, University College London, London, United Kingdom
| | - Peter Martin
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Claire Nightingale
- Department of Applied Health Research, University College London, London, United Kingdom.,Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | | | | | | | | | | | | | - Gareth Jones
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jennifer Cross
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Sarah Stanley
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Mary Emerson
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Charles Merrick
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Geraint Rees
- Faculty of Life Sciences, University College London, London, United Kingdom
| | | | - Rosalind Raine
- Department of Applied Health Research, University College London, London, United Kingdom
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The ICE-AKI study: Impact analysis of a Clinical prediction rule and Electronic AKI alert in general medical patients. PLoS One 2018; 13:e0200584. [PMID: 30089118 PMCID: PMC6082509 DOI: 10.1371/journal.pone.0200584] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes. METHODS AND FINDINGS A controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014-16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981-1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858-0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560-0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation. CONCLUSIONS In acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness. TRIAL REGISTRATION Clinicaltrials.org NCT03047382.
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Martindale AM, Elvey R, Howard SJ, McCorkindale S, Sinha S, Blakeman T. Understanding the implementation of 'sick day guidance' to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation. BMJ Open 2017; 7:e017241. [PMID: 29122792 PMCID: PMC5695520 DOI: 10.1136/bmjopen-2017-017241] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings. DESIGN Qualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance. SETTING A single primary care health setting in the North of England. PARTICIPANTS 29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients. INTERVENTION The sick day guidance intervention was rolled out (2015-2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a 'medicine sick day guidance' card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards. RESULTS Implementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage. CONCLUSIONS Sick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.
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Affiliation(s)
- Anne-Marie Martindale
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rebecca Elvey
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
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Acute kidney injury: Preventing acute kidney injury through nephrotoxin management. Nat Rev Nephrol 2016; 12:511-2. [PMID: 27374917 DOI: 10.1038/nrneph.2016.95] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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