The relative effectiveness of practice change interventions in overcoming common barriers to change: a survey of 14 hospitals with experience implementing evidence-based guidelines

@MondayNightIBD and the expanding gastroenterology Twitterverse: A study on continuing medical education on #GITwitter

OBJECTIVES

@MondayNightIBD provides weekly continuing medical education (CME) activities focused on inflammatory bowel diseases to clinicians on Twitter. Given its novelty, we assessed whether @MondayNightIBD improves learner knowledge and leads to practice change. We also examined whether inflammatory bowel disease topics addressed in @MondayNightIBD are aligned with entrustable professional activities (EPAs) set forth by national gastroenterology societies.

METHODS

@MondayNightIBD CME sessions from February 2020 (date the handle was accredited to provide CME) to May 2021 were analyzed. Pre- and post-activity knowledge was assessed for average score improvement using student's T-tests and Cohen's D effect size. Post-activity surveys examined for learners' perceptions of whether activities met educational goals and affected willingness to change clinical practice using descriptive percentages. In addition, activities from April 2019 (date of @MondayNightIBD inception) to May 2021 were assessed for whether they address EPAs set forth by national gastroenterology societies.

RESULTS

Learners' knowledge improved after @MondayNightIBD activities with average pre-activity correct answers of 58% to a post-activity average of 79% (p < 0.001). Greater than 95% of learners found that activities met learning objectives and enhanced knowledge. A total of 92% of learners were committed to practice change because of their @MondayNightIBD participation. Finally, 78% of EPAs set forth by a national gastroenterology society have been covered by @MondayNightIBD since its inception.

CONCLUSIONS

@MondayNightIBD is a Twitter-based CME activities platform for gastroenterologists and other clinicians that is embraced by learners, improves knowledge, and encourages practice change. Topics covered during @MondayNightIBD are aligned with EPAs set forth by national gastroenterology societies. @MondayNightIBD is a successful model of social media medical education, and a novel approach to effectively provide evidence-based CME.

Effectiveness of "Be SAFE Drowning Prevention and Water Safety Booklet" Intervention for Parents and Guardians

Background:

We aimed to assess the effectiveness of the health educational booklet intervention in improving parents/guardian’s knowledge on prevention of child drowning and, the perception of drowning risk and water safety practice.

Methods:

A quasi-experimental study was conducted in year 2017 in Selangor, Malaysia among 719 parents/guardians of primary school children. The parent/guardians were randomly assigned as the intervention groups and were given a health educational Be-SAFE booklet on drowning prevention and water safety. The pretest was conducted before the intervention and posttest was done one month of intervention. The data collection tool was using a validated questionnaire on knowledge, attitude and practice for drowning prevention and water safety.

Results:

There were 719 respondents (response rate of 89.9%) participated at baseline and 53.7% at end line (after the intervention). Significant differences found in knowledge, attitudes and practice on drowning prevention and water safety for the intervention and control groups after the intervention (P<0.001). There was a significant difference in mean scores for knowledge and attitude before and after the intervention, whereas no significant findings noted for practices (P<0.001).

Conclusion:

Be SAFE booklet contributed to the increase in parents/guardian’s knowledge and attitudes towards drowning prevention and water safety to prevent the risk of child drowning.

Implementation strategies for guidelines at ICUs: a systematic review

Purpose The purpose of this paper is to critically analyze empirical studies related to the implementation strategies for clinical practice guidelines (CPGs) in intensive care units (ICUs). Design/methodology/approach A systematic review with a narrative synthesis adapted from Popay et al.'s method for a narrative synthesis was conducted. A search using CINAHL, Google Scholar, Academic search complete, Cochrane Register for Randomized Controlled Trials, MEDLINE via PUBMED and grey literature was conducted in 2014 and updated in 2016 (August). After reading the abstracts, titles and full-text articles, 11 ( n=11) research studies met the inclusion criteria. Findings After critical appraisal, using the Joanna Briggs Critical Appraisal Tools, eight randomized controlled trials conducted in adult and neonatal ICUs using implementation strategies remained. Popay et al.'s method for narrative synthesis was adapted and used to analyze and synthesize the data and formulate concluding statements. Included studies found that multi-faceted strategies appear to be more effective than single strategies. Strategies mostly used were printed educational materials, information/ sessions, audit, feedback, use of champion leaders, educational outreach visits, and computer or internet usage. Practical training, monitoring visits and grand rounds were less used. Practical implications Findings can be used by clinicians to implement the best combination of multi-faceted implementation strategies in the ICUs in order to enhance the optimal use of CPGs. Originality/value No systematic review was previously done on the implementation strategies that should be used best for optimal CPG implementation in the ICU.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

Quality Improvement in Concussion Care: Influence of Guideline-Based Education

OBJECTIVE

To evaluate the potential impact of a concussion management education program on community-practicing pediatricians.

STUDY DESIGN

We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion.

RESULTS

Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns).

CONCLUSIONS

Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.

Why (we think) facilitation works: insights from organizational learning theory

Background

Facilitation is a guided interactional process that has been popularized in health care. Its popularity arises from its potential to support uptake and application of scientific knowledge that stands to improve clinical and managerial decision-making, practice, and ultimately patient outcomes and organizational performance. While this popular concept has garnered attention in health services research, we know that both the content of facilitation and its impact on knowledge implementation vary. The basis of this variation is poorly understood, and understanding is hampered by a lack of conceptual clarity.

Discussion

In this paper, we argue that our understanding of facilitation and its effects is limited in part by a lack of clear theoretical grounding. We propose a theoretical home for facilitation in organizational learning theory. Referring to extant literature on facilitation and drawing on theoretical literature, we discuss the features of facilitation that suggest its role in contributing to learning capacity. We describe how facilitation may contribute to generating knowledge about the application of new scientific knowledge in health-care organizations.

Summary

Facilitation’s promise, we suggest, lies in its potential to stimulate higher-order learning in organizations through experimenting with, generating learning about, and sustaining small-scale adaptations to organizational processes and work routines. The varied effectiveness of facilitation observed in the literature is associated with the presence or absence of factors known to influence organizational learning, since facilitation itself appears to act as a learning mechanism. We offer propositions regarding the relationships between facilitation processes and key organizational learning concepts that have the potential to guide future work to further our understanding of the role that facilitation plays in learning and knowledge generation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0323-0) contains supplementary material, which is available to authorized users.

Transforming a conservative clinical setting: ICU nurses' strategies to improve care for patients' relatives through a participatory action research

This study focuses on change strategies generated through a dialogical-reflexive-participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained.

Effectiveness of multifaceted and tailored strategies to implement a fall-prevention guideline into acute care nursing practice: a before-and-after, mixed-method study using a participatory action research approach

Background

Research- and/or evidence-based knowledge are not routinely adopted in healthcare and nursing practice. It is also unclear which implementation strategies are effective in nursing practice and what expenditures of time and money are required for the successful implementation of clinical practice guidelines (CPGs). The aim in this study was to assess the effectiveness and required time investment of multifaceted and tailored strategies for implementing an evidence-based fall-prevention guideline (Falls CPG) into nursing practice in an acute care hospital setting.

Methods

A before-and-after, mixed-method design was used within a participatory action research approach (PAR). The study was carried out in two departments of an Austrian university teaching hospital and included all graduate and assistant nurses. Data were collected through a questionnaire, group discussions and semi-structured interviews. Qualitative data were content-analysed using a template based on the Consolidated Framework for Implementation Research (CFIR), which also served as a theoretical framework for the study. Quantitative data were descriptively analysed using appropriate tests for independent groups.

Results

By applying multifaceted and tailored implementation strategies, the graduate and assistant nurses’ knowledge on fall prevention, how to access the Falls CPG and the guideline itself increased significantly between baseline and final assessment (p ≤ .001). Qualitative data also revealed an increase in participant awareness of fall prevention. A baseline positive attitude towards guidelines improved significantly towards the end of the project (p = .001). Required fall prevention equipment like baby monitors or one-way glide sheets were available for use and any required environmental adaptations, e.g. a handrail in the corridor, were made. Hospital nursing personnel (approximately 150) invested a total of 1192 hours of working time over the course of the project.

Conclusions

Multifaceted strategies tailored to the specific setting within a PAR approach and guided by the CFIR enabled the effective implementation of a CPG into acute care nursing practice. Nursing managers now have sound knowledge of the time resources required for CPG implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-015-0064-z) contains supplementary material, which is available to authorized users.

Factors affecting speech pathologists' implementation of stroke management guidelines: a thematic analysis

PURPOSE

Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be underutilised. There is limited research into the reasons for this, especially in speech pathology. This study provides the first in-depth, qualitative examination of the barriers and facilitators that speech pathologists perceive and experience when implementing guidelines.

METHODS

A maximum variation sample of eight speech pathologists participated in a semi-structured interview concerning the implementation of the National Stroke Foundation's Clinical Guidelines for Stroke Management 2010. Interviews were transcribed, thematically analysed and member checked before overall themes were identified.

RESULTS

Three main themes and ten subthemes were identified. The first main theme, making implementation explicit, reflected the necessity of accessing and understanding guideline recommendations, and focussing specifically on implementation in context. In the second theme, demand versus ability to change, the size of changes required was compared with available resources and collaboration. The final theme, Speech pathologist motivation to implement guidelines, demonstrated the influence of individual perception of the guidelines and personal commitment to improved practice.

CONCLUSIONS

Factors affecting implementation are complex, and are not exclusively barriers or facilitators. Some potential implementation strategies are suggested. Further research is recommended.

IMPLICATIONS FOR REHABILITATION

In most Western nations, stroke remains the single greatest cause of disability, including communication and swallowing disabilities. Although adherence to stroke clinical practice guidelines improves stroke patient outcomes, guidelines continue to be underutilised, and the reasons for this are not well understood. This is the first in-depth qualitative study identifying the complex barriers and facilitators to guideline implementation as experienced by speech pathologists in stroke care. Suggested implementation strategies include local monitoring of guideline implementation (e.g. team meetings, audits), increasing collaboration on implementation projects (e.g. managerial involvement, networking), and seeking speech pathologist input into guideline development.

The development of a clinical practice guideline to improve sleep in intensive care patients: a solution focused approach

OBJECTIVE

Our objective was to develop a guideline to improve the opportunity for intensive care patients to rest and sleep.

DESIGN AND SETTING

A pragmatic solution focused approach to guideline development and implementation was used in which data from international literature and original research from the study ICU were appraised in extensive consultation with intensive care staff. Audits were conducted early in the implementation phase to measure adoption rates.

RESULTS

Over 320 suggestions were made for inclusion in a practice guideline. Information was integrated to create the guideline. A comprehensive 'rest and sleep for the intensive care patient' guideline was developed comprising two main themes: 'Optimise the environment' (for example, 'Quiet conversation') and 'Rest and sleep interventions' (for example, 'Provide optimal conditions for night-time sleep'). Audit data suggested that adoption of the guideline had begun but was not yet embedded in practice.

CONCLUSION

The solution focused approach to addressing improvements ICU patients' sleep and the consideration of multiple sources of evidence resulted in the development of a comprehensive, context specific guideline. The process, based on a solution focus, may overcome difficulties faced by clinicians endeavouring to improve health care when there is a lack of high level evidence.

Use of local data to enhance uptake of published recommendations: an example from the diagnostic evaluation of precocious puberty

BACKGROUND

It has been recommended that basal luteinising hormone (LH) levels be used as the initial test to identify cases of central precocious puberty (CPP) in children. However, in clinical practice, gonadotropin-releasing hormone (GnRH) stimulation tests are frequently still used.

OBJECTIVE

To assess the diagnostic utility of a single LH to identify CPP in girls, as a means to safely reduce GnRH stimulation testing rates.

DESIGN

Retrospective analysis of patients referred for GnRH stimulation between August 2007 and December 2010, with prospective 12-month follow-up of GnRH stimulation testing rates post implementation of management algorithm.

PATIENTS

57 girls (6.2 ± 2.1 years) with early signs of puberty.

MAIN OUTCOME MEASURE

Ability of basal LH to predict clinical pubertal progression, 6 months following the GnRH stimulation test.

RESULTS

Pubertal progression occurred in 18 patients. All patients with a basal LH level ≥ 0.3 IU/L had subsequent pubertal progression, while 39 of 41 patients with a basal LH ≤ 0.2 IU/L did not progress, resulting in 100% specificity (95% CI 92% to 100%) and 90.5% sensitivity (69.6% to 98.8%). Using the locally derived algorithm, GnRH stimulation testing was redirected to patients with pubertal progression that was discordant with basal LH data. Post intervention, there was a 75% reduction in GnRH stimulation testing without comprising the rate of diagnosis of CPP.

CONCLUSIONS

Our results confirm the diagnostic utility of basal LH levels in the diagnosis of CPP and demonstrate that dissemination and interpretation of local data may facilitate change in clinical practice, resulting in streamlined patient care and cost savings.

Implementation Interventions Used in Nursing Homes and Hospitals: A Descriptive, Comparative Study between Austria, Germany, and The Netherlands

Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.

The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit

BACKGROUND

A nutrition support algorithm is an operational version of a guideline that is adapted to local requirements and easy to apply in clinical practice. The purpose of this study was to determine the impact of implementing a nutrition support algorithm on nutrition care outcomes in an intensive care unit (ICU) in Switzerland without a designated dietitian.

METHODS

The retrospective study included data collection on 2 cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of a nutrition support algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines.

RESULTS

There were significant differences between groups for the mean delivery of total energy in the pre- vs postimplementation group (909 ± 444 vs 1097 ± 420 kcal/d; P = .023) and mean delivery of protein per day (35 ± 17.9 vs 59.1 ± 27.3 g; P < .001). For patients staying at least 7 days in the ICU, the cumulative energy deficit decreased from -5664 ± 3613 kcal in the preimplementation group to -2972 ± 2420 kcal (P = .011) in the postimplementation group. No significant differences in the route of feeding and timing of enteral nutrition initiation were found.

CONCLUSIONS

Implementation of a nutrition support algorithm resulted in improved provision of energy and protein delivery. This may be further improved with routine nutrition assessment by a dietitian or a designated nutrition support team.

Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia

BACKGROUND

In an era when an increasing amount of clinical information is available to health care professionals, the effective implementation of clinical practice guidelines requires the development of strategies to facilitate the use of these guidelines. The objective of this study was to assess attitudes towards clinical practice guidelines, as well as the barriers and facilitators to their use, among Estonian physicians. The study was conducted to inform the revision of the clinical practice guideline development process and can provide inspiration to other countries considering the increasing use of evidence-based medicine.

METHODS

We conducted an online survey of physicians to assess resource, system, and attitudinal barriers. We also asked a set of questions related to improving the use of clinical practice guidelines and collected free-text comments. We hypothesized that attitudes concerning guidelines may differ by gender, years of experience and practice setting. The study population consisted of physicians from the database of the Department of Continuing Medical Education of the University of Tartu. Differences between groups were analyzed using the Kruskal-Wallis non-parametric test.

RESULTS

41% (497/1212) of physicians in the database completed the questionnaire, comprising more than 10% of physicians in the country. Most respondents (79%) used treatment guidelines in their daily clinical practice. Lack of time was the barrier identified by the most physicians (42%), followed by lack of medical resources for implementation (32%). The majority of physicians disagreed with the statement that guidelines were not accessible (73%) or too complicated (70%). Physicians practicing in outpatient settings or for more than 25 years were the most likely to experience difficulties in guideline use. 95% of respondents agreed that an easy-to-find online database of guidelines would facilitate use.

CONCLUSIONS

Use of updated evidence-based guidelines is a prerequisite for the high-quality management of diseases, and recognizing the factors that affect guideline compliance makes it possible to work towards improving guideline adherence in clinical practice. In our study, physicians with long-term clinical experience and doctors in outpatient settings perceived more barriers, which should be taken into account when planning strategies in improving the use of guidelines. Informed by the results of the survey, leading health authorities are making an effort to develop specially designed interventions to implement clinical practice guidelines, including an easily accessible online database.

The effect of a translating research into practice (TRIP)--cancer intervention on cancer pain management in older adults in hospice

BACKGROUND

Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and who have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain-free death, and while outcomes are better in hospice, patients still die with poorly controlled pain.

OBJECTIVE

This article reports on the results of a Translating Research into Practice intervention designed to promote the adoption of evidence-based pain practices for older adults with cancer in community-based hospices.

SETTING

  This Institutional Human Subjects Review Board-approved study was a cluster randomized controlled trial implemented in 16 Midwestern hospices.

METHODS

Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed.

RESULTS

Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence-based practices for the experimental sites, was not significantly greater than control sites. Decrease in patient pain severity from baseline to post-intervention in the experimental group was greater; however, the result was not statistically significant (P = 0.1032).

CONCLUSIONS

Findings indicate a number of factors that may impact implementation of multicomponent interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest that future study is needed on specific factors to target when implementing a community-based hospice intervention, including determining and measuring intervention fidelity prospectively.

Redesigning the ICU nursing discharge process: a quality improvement study

PURPOSE

To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours.

METHODS

A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge.

RESULTS

A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention).

CONCLUSIONS

Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice.

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

BACKGROUND

The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines.

METHODS

The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e-mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice.

RESULTS

Twenty-six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes.

CONCLUSION

Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.

Nutritional therapy in patients with acute pancreatitis requiring critical care unit management: a prospective observational study in Australia and New Zealand

OBJECTIVE

To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition.

DESIGN

Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months.

SETTING

Intensive care units or high-dependency units within Australia and New Zealand.

PATIENTS

Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded.

MEASUREMENTS

The primary outcome was the proportion of patients who received enteral nutrition, parenteral nutrition, or concurrent enteral nutrition/parenteral nutrition. Secondary outcomes included other aspects of nutritional therapy and the severity and clinical outcomes of acute pancreatitis.

MEASUREMENTS AND MAIN RESULTS

We enrolled 121 patients and 117 were analyzed. The mean age was 61 (sd 17) years and 53% were men. Enteral nutrition was delivered to 58 (50%; 95% confidence interval [CI], 41-59%) and parenteral nutrition to 49 (42%; 95% CI, 33-51%) patients. Parenteral nutrition was more frequently used as the initial therapy (58%; 95% CI, 49-67%) than enteral nutrition (42%; 95% CI, 33-51%). The most common reason for parenteral nutrition prescription was the treating doctor's preference (60%). Enteral nutrition (74%) was more often used than parenteral nutrition (40%) on any individual study day. Concurrent enteral nutrition and parenteral nutrition occurred in 28 (24%) patients on 14% of days. Complications of acute pancreatitis requiring critical care unit management were observed in 45 (39%) patients. The median (interquartile range) duration of intensive care unit and hospital stay were 5 (2-10) and 19 (9-31) days, respectively. The hospital mortality rate was 15% (95% CI, 8-21%), and there was a tendency toward higher mortality for patients who only received parenteral nutrition than for those who only received enteral nutrition (28% vs. 7%, p=.06).

CONCLUSIONS

For patients with acute pancreatitis requiring critical care unit management in Australian and New Zealand intensive care units, enteral nutrition is used most commonly, but parenteral nutrition is more often used as the initial route of nutritional therapy. Given that clinical practice guidelines currently recommend enteral nutrition as the initial route of nutritional therapy in severe acute pancreatitis, improved education about and dissemination of these guidelines seems warranted.

Implementing a web-based oncology protocol system in Australia: evaluation of the first 3 years of operation

BACKGROUND

EviQ is a web-based oncology protocol system launched across Australia in 2005 (http://www.eviq.org.au). We evaluated eviQ use at the point-of-care and determined the factors impacting on its uptake and routine use in the first three years of operation.

METHODS

We conducted a suite of qualitative and quantitative studies with over 200 Australian oncology physicians, nurses and pharmacists working at treatment centres in diverse geographical locations.

RESULTS

EviQ was part of routine care at many hospitals; however, the way in which it was used at the point-of-care varies according to clinician roles and hospital location. We identified a range of factors impacting on eviQ uptake and routine use. Infrastructure, such as availability of point-of-care computers, and formal policies endorsing eviQ are fundamental to increasing uptake. Furthermore, the level of clinical and computer experience of end-users, the attitudes and behaviour of clinicians, endorsement and promotion strategies, and level and type of eviQ education all need to be considered and managed to ensure that the system is being used to its full potential.

CONCLUSION

Our findings show that the dissemination of web-based treatment protocols does not guarantee widespread use. Organisational, environmental and clinician-specific factors play a role in uptake and utilisation. The deployment of sufficient computer infrastructure, implementation of targeted training programmes and hospital policies and investment in marketing approaches are fundamental to uptake and continued use. This study highlights the value of ongoing monitoring and evaluation to ensure systems like eviQ achieve their primary purpose - reducing treatment variation and improving quality of care.

[Development of an attention guideline for the critical patient's family]

INTRODUCTION

Within the context of participatory action research (PAR) at an Intensive Care Unit (ICU), 4 proposals for change were agreed by consensus to improve the attention given to families of critical patients. One proposal was the creation of a guideline for attending to family members, inspired by the participants' desire to improve the attention given to this group of users.

OBJECTIVES

1) To design a guide that would meet the needs of professionals and users. 2) To reach an agreement on the minimum requirements for attention given to families of critical patients.

MATERIALS AND METHODS

Qualitative methodology, based on PAR. For each of the initiatives, a working group was created, composed mainly of professionals from the ICU coordinated by a researcher. In the case of the guide, an online community was also created as a working tool to speed up communications among the participants, reducing the number of face-to-face sessions. Participation was voluntary. To draft the guideline, a Clinical Practice Guideline for support the family was made available, which had been translated into Spanish, together with an up-to-date bibliography.

RESULTS

Twenty four professionals were involved. We developed a guide that contained the following sections: introduction, objectives, the experiences and needs of families of patients in the ICU, strategies for action, specific procedures, and hospital resources. We designed strategies for the diffusion and implementation of the guide.

CONCLUSIONS

The guide is a useful tool that offers the professionals greater assurances and unifying criteria for action. During subsequent stages of the PAR project, an assessment will be made of the impact on professionals and users.

Survey of knowledge and perception on the access to evidence-based practice and clinical practice change among maternal and infant health practitioners in South East Asia

Background

Evidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia.

Methods

Questionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines.

Results

The survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high.

Conclusion

This survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively.