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Lirette MP, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Florin TA, Babl FE, Dalziel S, Freedman S, Roland D, Lyttle MD, Schnadower D, Steele D, Fernandes RM, Stephens D, Kharbanda A, Johnson DW, Macias C, Benito J, Schuh S. International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study. BMJ Open 2022; 12:e059784. [PMID: 36600373 PMCID: PMC9730363 DOI: 10.1136/bmjopen-2021-059784] [Citation(s) in RCA: 6] [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: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days. DESIGN A secondary analysis of a retrospective cohort study. SETTING 38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal. PATIENTS Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013. OUTCOME MEASURES Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits. RESULTS 1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)). CONCLUSIONS Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.
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Affiliation(s)
- Marie-Pier Lirette
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Kuppermann
- The Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
- University of California Davis Health System, Sacramento, California, USA
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Todd Adam Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Franz E Babl
- Emergency Department, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne/The Royal Children's Hospital CICH, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Stephen Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Mark David Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dale Steele
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Derek Stephens
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - David W Johnson
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Charles Macias
- Division of Pediatric Emergency Medicine, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Ramsden V, Middleton S, McInnes E, Babl FE, Tavender E. Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction. Emerg Med Australas 2022; 34:670-674. [PMID: 35918063 DOI: 10.1111/1742-6723.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
Despite an increased focus on ways to improve implementation of evidence and de-implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting.
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Affiliation(s)
- Victoria Ramsden
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Midwifery and Health Sciences, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Elizabeth McInnes
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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3
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Ramsden V, Babl FE, Dalziel SR, Middleton S, Oakley E, Haskell L, Lithgow A, Orsini F, Schembri R, Wallace A, Wilson CL, McInnes E, Wilson PH, Tavender E. Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol. BMC Health Serv Res 2022; 22:1099. [PMID: 36038929 PMCID: PMC9423692 DOI: 10.1186/s12913-022-08450-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. Methods A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. Discussion This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. Trial registration Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
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Affiliation(s)
- Victoria Ramsden
- Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.,Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia.,St Vincent's Hospital, Level 5 DeLacy Building, Victoria Road, Darlinghurst, NSW, 2010, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Libby Haskell
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Anna Lithgow
- Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Northern Territory, 0810, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Alexandra Wallace
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Department of Paediatrics, Waikato Hospital, Selwyn St, Hamilton Central, Hamilton, 3204, New Zealand
| | - Catherine L Wilson
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia
| | - Peter H Wilson
- Australian Catholic University, Building 460, Level 8, 250 Victoria Parade, East Melbourne, Victoria, 3002, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia.
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4
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Chun A, Panchmatia R, Doan Q, Meckler G, Narayan B. Twitter as a Knowledge Translation Tool to Increase Awareness of the OpenHEARTSMAP Psychosocial Assessment and Management Tool in the Field of Pediatric Emergency Mental Health. Cureus 2022; 14:e27597. [PMID: 36059355 PMCID: PMC9433791 DOI: 10.7759/cureus.27597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale The increasing prevalence of pediatric mental health presentations in pediatric emergency departments (PED) requires improved integration of evidence-based management strategies. Social media, specifically Twitter, has shown potential to aid in closing the knowledge translation (KT) gap between these evidence-based management strategies and pediatric emergency medicine (PEM) providers. Aims and objectives The primary outcome of this study is to evaluate the effectiveness of Twitter as a KT dissemination tool in PEM. The exploratory outcomes were to assess how to effectively implement Twitter in KT, explore ways in which Twitter can maximize the global reach of OpenHEARTSMAP and whether Twitter can lead to increased adoption of OpenHEARTSMAP. Methods A one-week prospective promotion on Twitter was conducted to disseminate the OpenHEARTSMAP tool using 15 topic-related hashtags (arm 1, 15 Tweets) versus one post wherein 15 different Twitter users were mentioned in 15 different comments (arm 2, 1 Tweet). A one-week control period immediately prior to posting was employed for comparisons. Results During the Twitter week, visits per day to OpenHEARTSMAP increased by 175%; mean time spent on the website increased by 212%; and mean page actions per visit increased by 130%. The greatest increase in visits occurred on the first day of Tweeting. Arm 2 received the greatest engagements. Within arm 1, the category of pediatrics received the most engagements (hashtag #Peds was most popular). Arm 1 received 455 impressions compared to 2071 in arm 2. No new users registered an account on the OpenHEARTSMAP website, which is required to physically use the tool. Conclusion Twitter can be an effective KT tool to increase awareness of research, the first step of KT, in the domain of PEM mental health care. Strategies for success include building a robust Twitter following; posting during peak healthcare-related Twitter traffic times; employing hashtags coinciding with current events; and targeting posts by tagging users who need not necessarily be generally well-known opinion leaders.
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5
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Uwizeye CB, Zomahoun HTV, Bussières A, Thomas A, Kairy D, Massougbodji J, Rheault N, Tchoubi S, Philibert L, Abib Gaye S, Khadraoui L, Ben Charif A, Diendéré E, Langlois L, Dugas M, Légaré F. Implementation strategies for knowledge products in primary healthcare: a systematic review of systematic reviews (Preprint). Interact J Med Res 2022; 11:e38419. [PMID: 35635786 PMCID: PMC9315889 DOI: 10.2196/38419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background The underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception. Objective This study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured. Methods We performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis. Results Of the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level. Conclusions Clinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.
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Affiliation(s)
- Claude Bernard Uwizeye
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Hervé Tchala Vignon Zomahoun
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Department of Social and Preventive Medicine, Laval University, Québec, QC, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal métropolitain (CRIR), Montreal, QC, Canada
- Réseau Provincial de recherche en Adaptation-Réadaptation (REPAR), Montreal, QC, Canada
| | - Aliki Thomas
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal métropolitain (CRIR), Montreal, QC, Canada
- Réseau Provincial de recherche en Adaptation-Réadaptation (REPAR), Montreal, QC, Canada
| | - Dahlia Kairy
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal métropolitain (CRIR), Montreal, QC, Canada
- Réseau Provincial de recherche en Adaptation-Réadaptation (REPAR), Montreal, QC, Canada
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montreal, QC, Canada
| | - José Massougbodji
- Department of Social and Preventive Medicine, Laval University, Québec, QC, Canada
- Institut National de Santé Publique du Québec, Québec, QC, Canada
| | - Nathalie Rheault
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Sébastien Tchoubi
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- Department of Social and Preventive Medicine, Laval University, Québec, QC, Canada
| | - Leonel Philibert
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- Faculty of Nursing, Laval University, Québec, QC, Canada
| | - Serigne Abib Gaye
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
| | - Lobna Khadraoui
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Ali Ben Charif
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Laval University, Québec, QC, Canada
- CubecXpert, Québec, QC, Canada
| | - Ella Diendéré
- Institut National de Santé Publique du Québec, Québec, QC, Canada
| | - Léa Langlois
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - Michèle Dugas
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
| | - France Légaré
- Learning Health System Component of the Québec Strategy for Patient-Oriented Research (SPOR) - Support for People and Patient-Oriented and Trials (SUPPORT) Unit, Québec, QC, Canada
- VITAM Research Center on Sustainable Health, Laval University, Québec, QC, Canada
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Department of Family Medicine and Emergency Medicine, Laval University, Québec, QC, Canada
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6
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Haskell L, Tavender EJ, Wilson CL, O'Brien S, Babl FE, Borland ML, Cotterell E, Sheridan N, Oakley E, Dalziel SR. Development of targeted, theory-informed interventions to improve bronchiolitis management. BMC Health Serv Res 2021; 21:769. [PMID: 34344383 PMCID: PMC8335893 DOI: 10.1186/s12913-021-06724-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. METHODS A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. RESULTS Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. CONCLUSION A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Curtin University, Perth, Western Australia, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Austalia, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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Haskell L, Tavender EJ, Wilson CL, O’Brien S, Babl FE, Borland ML, Cotterell E, Schembri R, Orsini F, Sheridan N, Johnson DW, Oakley E, Dalziel SR. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:797-806. [PMID: 33843971 PMCID: PMC8042564 DOI: 10.1001/jamapediatrics.2021.0295] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care. OBJECTIVE To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020. INTERVENTIONS Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback. MAIN OUTCOMES AND MEASURES The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions. RESULTS A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001). CONCLUSIONS AND RELEVANCE Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
| | - Emma J. Tavender
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Catherine L. Wilson
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Sharon O’Brien
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Curtin University, Bentley, Western Australia, Australia
| | - Franz E. Babl
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Pediatric Emergency Medicine, University of Melbourne, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Faculty of Health and Medical Sciences (Pediatrics and Emergency Medicine), The University of Western Australia, Western Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, New South Wales, Australia,School of Rural Medicine, University of New England, New South Wales, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Nicolette Sheridan
- Center for Nursing and Health Research, Massey University, Auckland, Auckland, New Zealand
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ed Oakley
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia,University of Melbourne, Victoria, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand,Departments of Surgery and Pediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
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8
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Babl FE, Tavender E, Dalziel SR. From knowledge generation to synthesis to translation. Emerg Med Australas 2021; 33:192-194. [PMID: 33733626 DOI: 10.1111/1742-6723.13759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Franz E Babl
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
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Schadewaldt V, McElduff B, D'Este C, McInnes E, Dale S, Fasugba O, Cadilhac DA, Considine J, Grimshaw JM, Cheung NW, Levi C, Gerraty R, Fitzgerald M, Middleton S. Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes. Nurs Outlook 2020; 69:103-115. [PMID: 32981669 DOI: 10.1016/j.outlook.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/22/2020] [Accepted: 08/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. PURPOSE To identify how context affects the provision of stroke care in 26 Australian EDs. METHOD Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FINDINGS Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DISCUSSION Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.
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Affiliation(s)
- Verena Schadewaldt
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia.
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Catherine D'Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australia; School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Oyebola Fasugba
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Julie Considine
- Deakin University - Eastern Health; School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Victoria, Australia
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital - General Campus, Centre for Practice-Changing Research (CPCR), Ottawa, Ontario, Canada
| | - N Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead, Sydney, New South Wales, Australia
| | - Chris Levi
- The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Liverpool, New South Wales, Australia
| | - Richard Gerraty
- Department of Medicine, Monash University, Melbourne, Australia
| | - Mark Fitzgerald
- Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Darlinghurst, New South Wales, Australia
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Yeo YL, O'Brien S, Bear N, Borland ML. Knowledge translation in Western Australia tertiary paediatric emergency department: An audit cycle of effectiveness of guideline dissemination on bronchiolitis management. J Paediatr Child Health 2020; 56:1358-1364. [PMID: 32663366 DOI: 10.1111/jpc.14930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/31/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022]
Abstract
AIM Bronchiolitis is the commonest cause of hospitalisation for infants. Evidence-based Australasian bronchiolitis guideline was developed and introduced in 2017. This audit was to determine if the knowledge translation process of the updated local tertiary hospital bronchiolitis guideline (based on the Australasian guideline) reduced unnecessary interventions. METHODS A retrospective chart review of infants with bronchiolitis diagnosis during the pre-guideline (1 July to 31 August 2015) and post-guideline (1 July to 31 August 2017) period, with the primary outcome of the number/proportion of unnecessary interventions. RESULTS Presentations between 1 July to 31 August 2015 (n = 465) were compared with 2017 (n = 343). There was no difference in undertaking chest X-ray (24 (5.2%) vs. 17 (5.0%), odds ratio (OR) 0.98 (95% confidence interval (CI) 0.71-1.35), P = 0.911), salbutamol (23 (4.9%) vs. 10 (2.9%), OR 0.86 (95% CI 0.65-1.13), P = 0.279), glucocorticoids (2 (0.4%) vs. 5 (1.5%), OR 1.89 (95% CI 0.83-4.31), p = 0.129), antibiotics (11 (2.4%) vs. 5 (1.5%), OR 0.86 (95% CI 0.65-1.15), P = 0.307) or nasopharyngeal aspirate (172 (37%) vs. 124 (36.2%), OR 1.00 (95% CI 0.87-1.67), P = 0.937) in hospital. Adrenaline was not administered in both years. There was reduced hospital admissions (303 (65.2%) vs. 192 (56.0%), OR 0.82 (95% CI 0.71-0.95), P = 0.008) with no difference in paediatric intensive care unit admissions (10 (2.2%) vs. 8 (2.3%), OR 1.04 (95% CI 0.65-1.67), P = 0.863). CONCLUSION The dissemination process of the updated local hospital bronchiolitis guideline did not show any statistically significant reduction of unnecessary interventions in the hospital. Further studies are required to determine the effective process to instigate changes in health services.
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Affiliation(s)
- Yee Lymn Yeo
- Emergency Department, Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Natasha Bear
- Department of Child Health Research, Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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11
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Haskell L, Tavender EJ, Wilson C, Babl FE, Oakley E, Sheridan N, Dalziel SR. Understanding factors that contribute to variations in bronchiolitis management in acute care settings: a qualitative study in Australia and New Zealand using the Theoretical Domains Framework. BMC Pediatr 2020; 20:189. [PMID: 32357866 PMCID: PMC7193400 DOI: 10.1186/s12887-020-02092-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 04/20/2020] [Indexed: 11/20/2022] Open
Abstract
Background Bronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework. Methods Semi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis. Results Between July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse’s reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of ‘paediatric confident’ nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources). Conclusions Factors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | - Ed Oakley
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | | | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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12
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Tavender E, Babl FE, Middleton S. Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction. Emerg Med Australas 2019; 31:332-338. [DOI: 10.1111/1742-6723.13296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Melbourne, Victoria Australia
- Department of PaediatricsThe University of Melbourne Melbourne Victoria Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Melbourne, Victoria Australia
- Department of PaediatricsThe University of Melbourne Melbourne Victoria Australia
- Emergency DepartmentThe Royal Children's Hospital Melbourne Victoria Australia
| | - Sandy Middleton
- Nursing Research InstituteSt Vincent's Health Australia and Australian Catholic University Sydney New South Wales Australia
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Chandra K, Atkinson PR, Chatur H, Fraser J, Adams CL. To Choose or Not To Choose: Evaluating the Effect of a Choosing Wisely Knowledge Translation Initiative for Imaging in Low Back Pain by Emergency Physicians. Cureus 2019; 11:e4002. [PMID: 30989011 PMCID: PMC6447138 DOI: 10.7759/cureus.4002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC)-EM recommendations. We then assessed whether a structured knowledge translation (KT) initiative affected awareness, knowledge, and practice patterns for imaging in low back pain. Methods: We completed a two-center, before and after practice evaluation study. Physicians working in two Canadian emergency departments (EDs) were asked to participate in a survey before a KT initiative, and were surveyed again at a six-month follow up period post-intervention. The primary outcome of physician practice was determined by analyzing the frequency of lumbar X-ray imaging for back pain. Results: A total of 37 physicians were asked to complete the pre- and post-intervention survey. Awareness of the CWC-EM recommendations increased following the intervention (63%; 95%CI: 43-79 at baseline vs. 86%; 66-96 post-intervention). Knowledge increased with 58% (39-76) of physicians responding correctly initially, and 86% (66-96) after the intervention. Despite increases in awareness and knowledge of the guidelines, the lumbar X-ray imaging rate increased from a baseline of 12% (9.9-14.5) to 16.2% (13.6-19.2; p = 0.023) following the intervention. Conclusion: We demonstrated some improvements in physician awareness and knowledge of the CWC-EM recommendations following our intervention. Despite these improvements, our KT intervention was associated with an increased frequency of imaging for low back pain, contrary to our expectations.
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Affiliation(s)
- Kavish Chandra
- Emergency Medicine, Dalhousie University, Saint John, CAN
| | - Paul R Atkinson
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - Hanif Chatur
- Emergency Medicine, Upper River Valley Hospital, Grafyon, CAN
| | | | - Cherie Lee Adams
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
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Haskell L, Tavender EJ, Wilson C, O’Brien S, Babl FE, Borland ML, Cotterell L, Schuster T, Orsini F, Sheridan N, Johnson D, Oakley E, Dalziel SR. Implementing evidence-based practices in the care of infants with bronchiolitis in Australasian acute care settings: study protocol for a cluster randomised controlled study. BMC Pediatr 2018; 18:218. [PMID: 29980177 PMCID: PMC6035428 DOI: 10.1186/s12887-018-1187-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for admission to hospital for infants less than one year of age. Although management is well defined, there is substantial variation in practice, with infants receiving ineffective therapies or management. This study will test the effectiveness of tailored, theory informed knowledge translation (KT) interventions to decrease the use of five clinical therapies or management processes known to be of no benefit, compared to usual dissemination practices in infants with bronchiolitis. The primary objective is to establish whether the KT interventions are effective in increasing compliance to five evidence based recommendations in the first 24 h following presentation to hospital. The five recommendations are that infants do not receive; salbutamol, antibiotics, glucocorticoids, adrenaline, or a chest x-ray. METHODS/DESIGN This study is designed as a cluster randomised controlled trial. We will recruit 24 hospitals in Australia and New Zealand, stratified by country and provision of tertiary or secondary paediatric care. Hospitals will be randomised to either control or intervention groups. Control hospitals will receive a copy of the recent Australasian Bronchiolitis Guideline. Intervention hospitals will receive KT interventions informed by a qualitative analysis of factors influencing clinician care of infants with bronchiolitis. Key interventions include, local stakeholder meetings, identifying medical and nursing clinical leads in both emergency departments and paediatric inpatient areas who will attend a single education train-the-trainer day to then deliver standardised staff education with the training materials provided and coordinate audit and feedback reports locally over the study period. Data will be extracted retrospectively for three years prior to the study intervention year, and for seven months of the study intervention year bronchiolitis season following intervention delivery to determine compliance with the five evidence-based recommendations. Data will be collected to assess fidelity to the implementation strategies and to facilitate an economic evaluation. DISCUSSION This study will contribute to the body of knowledge to determine the effectiveness of tailored, theory informed interventions in acute care paediatric settings, with the aim of reducing the evidence to practice gaps in the care of infants with bronchiolitis. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616001567415 (retrospectively registered on 14 November 2016).
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Murdoch Childrens Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | | | - Sharon O’Brien
- Princess Margaret Hospital for Children, Perth, Australia
| | - Franz E. Babl
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Meredith L. Borland
- Princess Margaret Hospital for Children, Perth, Australia
- Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Liz Cotterell
- Armidale Rural Referral Hospital, Armidale, NSW Australia
- University of New England, Armidale, NSW Australia
| | - Tibor Schuster
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | - Francesca Orsini
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | | | - David Johnson
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ed Oakley
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - on behalf of PREDICT
- Paediatric Research in Emergency Departments International Collaborative, Melbourne, Australia
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