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Burgess L, Theobald K, Kynoch K, Keogh S. Implementing Evidence-Based Pain Management Interventions Into an Emergency Department: Outcomes Guided by Use of the Ottawa Model of Research Use. J Adv Nurs 2024. [PMID: 39379283 DOI: 10.1111/jan.16457] [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: 11/18/2023] [Revised: 08/14/2024] [Accepted: 09/01/2024] [Indexed: 10/10/2024]
Abstract
AIM To implement strategies to improve the care of patients with acute pain in the emergency department (ED). DESIGN Pre-post implementation study using a Type 2 hybrid effectiveness-implementation design. METHODS Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation. RESULTS Improvements in time-to-analgesia within 30 min (21%-27%), administration of nurse-initiated analgesia (NIA) (17%-27%) and measurement of pain (65%-75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies. CONCLUSION Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study. IMPLICATIONS Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED. IMPACT This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used. PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution in this study.
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Affiliation(s)
- Luke Burgess
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Karen Theobald
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
| | - Kathryn Kynoch
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Samantha Keogh
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
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Winkler K, McKinney J, Reale C, Anders S, Rubenstein M, Cavagnini L, Crowe R, Ward MJ. A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome. PREHOSP EMERG CARE 2024:1-9. [PMID: 38981118 DOI: 10.1080/10903127.2024.2372817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS. METHODS In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes. RESULTS Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive. CONCLUSIONS Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.
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Affiliation(s)
- Kailey Winkler
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jared McKinney
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carrie Reale
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shilo Anders
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren Cavagnini
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee
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Chewe VM, Khunou SH. Midwifery hurdles: Navigating tuberculosis screening challenges in South Africa. Curationis 2024; 47:e1-e6. [PMID: 38949423 PMCID: PMC11219679 DOI: 10.4102/curationis.v47i1.2533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND In South Africa, screening for tuberculosis during pregnancy is a serious challenge. Tuberculosis is one of the leading indirect causes of mortality in pregnant women. OBJECTIVES The objective of the study was to explore the challenges experienced by midwives regarding tuberculosis in pregnant women. METHOD A qualitative exploratory research method was used to conduct the study. The study population comprised midwives who worked at primary healthcare clinics in the selected local area, Capricorn District, Limpopo province. Purposive non-probability sampling was used to select 10 participants. Data from participants were acquired using in-depth individual semi-structured interviews. Data analysis was carried out using manual thematic analysis following Tesch's technique. RESULTS The outcomes of this study included midwives knowing their roles regarding tuberculosis screening among pregnant women. They further highlighted their challenges while screening tuberculosis in pregnant women, such as shortage of screening tools, withholding of tuberculosis information, and language barrier. CONCLUSION Midwives should have the necessary equipment and be trained in various languages used in the province to improve tuberculosis screening among all pregnant women.Contribution: Infected pregnant women and their unborn children's health can be improved by tuberculosis screening.
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Affiliation(s)
- Violet M Chewe
- Department of Advanced Nursing Science, Faculty of Health Sciences, University of Venda, Thohoyandou.
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Aldahmashi H, Maneze D, Molloy L, Salamonson Y. Nurses' adoption of diabetes clinical practice guidelines in primary care and the impacts on patient outcomes and safety: An integrative review. Int J Nurs Stud 2024; 154:104747. [PMID: 38531197 DOI: 10.1016/j.ijnurstu.2024.104747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Complications related to diabetes mellitus impose substantial health and economic burdens to individuals and society. While clinical practice guidelines improve diabetes management in primary care settings, the variability in adherence to these guidelines persist. Hence, there is a need to comprehensively review existing evidence regarding factors influencing nurses' adherence to implementation of clinical practice guidelines to improve clinical care and patient safety. OBJECTIVE This integrative review seeks to investigate nurses' adherence to clinical guidelines for diabetes management in primary healthcare settings and to explore factors influencing effective implementation, focusing on the role of nurses and impacts on patient outcomes. METHODS A comprehensive search was conducted in March 2023 across six electronic databases. The search targeted studies that examined the use of Type 2 diabetes mellitus guidelines by nurses in primary healthcare settings with a focus on clinical management outcomes related to diabetes care or patient safety. Included studies were classified using the Effective Practice and Organisation of Care taxonomy, synthesised narratively and presented thematically. Reporting of the review adhered to PRISMA guidelines. (PROSPERO ID CRD42023394311). RESULTS The review included ten studies conducted between 2000 and 2020, and the results were categorised into three themes. These were: (i) Implementation strategies to promote clinical practice guidelines adherence, including health professional development, reminders for clinicians, patient-mediated interventions, health information systems, role expansion, and comprehensive package-of-care. A multifaceted educational approach emerged as the most effective strategy. (ii) Impact of guidelines adherence: These strategies consistently improved clinical management, lowering HbA1c levels, improving blood pressure and lipid profiles, and enhancing patient self-care engagement, along with increased nurses' adherence to diabetes clinical guidelines. (iii) The role of nurses in guideline implementation, enabling independent practice within multidisciplinary teams. Their roles encompassed patient education, collaborative practice with fellow healthcare professionals, program planning and execution, and comprehensive documentation review. Nurse-led interventions were effective in improving patient outcomes, underscoring the necessity of empowering nurses with greater autonomy in providing primary diabetes care. CONCLUSION Implementing a diverse range of strategies, focusing on comprehensive education for healthcare providers, is paramount for enhancing guideline adherence in diabetes care, to improve clinical management towards optimal patient health outcomes. Tailoring these strategies to meet local needs adds relevance to the guidelines. Empowering nurses to take a leading role in primary care not only enhances patient safety but also promotes quality of care, resulting in improved overall outcomes. TWEETABLE ABSTRACT In primary care, empowering nurses with diabetes guideline education and tailoring strategies to local needs enhance guideline adherence and improve patient outcomes.
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Affiliation(s)
- Hadwan Aldahmashi
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; College of Applied Medical Sciences, University of Hafr Albatin, Saudi Arabia.
| | - Della Maneze
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Australian Centre for Integration of Oral Health, Australia.
| | - Luke Molloy
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia.
| | - Yenna Salamonson
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; Australian Centre for Integration of Oral Health, Australia.
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Adukauskienė D, Mickus R, Dambrauskienė A, Vanagas T, Adukauskaitė A. Improving Clostridioides difficile Infectious Disease Treatment Response via Adherence to Clinical Practice Guidelines. Antibiotics (Basel) 2024; 13:51. [PMID: 38247610 PMCID: PMC10812669 DOI: 10.3390/antibiotics13010051] [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: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Clostridioides difficile (C. difficile) is a predominant nosocomial infection, and guidelines for improving diagnosis and treatment were published in 2017. We conducted a single-center, retrospective 10-year cohort study of patients with primary C. difficile infectious disease (CDID) at the largest referral Lithuanian university hospital, aiming to evaluate the clinical and laboratory characteristics of CDID and their association with the outcomes, as well as implication of concordance with current Clinical Practice Guidelines. The study enrolled a total of 370 patients. Cases with non-concordant CDID treatment resulted in more CDID-related Intensive Care Unit (ICU) admissions (7.5 vs. 1.8%) and higher CDID-related mortality (13.0 vs. 1.8%) as well as 30-day all-cause mortality (61.0 vs. 36.1%) and a lower 30-day survival compared with CDID cases with concordant treatment (p < 0.05). Among cases defined by two criteria for severe CDID, only patients with non-concordant metronidazole treatment had refractory CDID (68.8 vs. 0.0%) compared with concordant vancomycin treatment. In the presence of non-concordant metronidazole treatment for severe CDID, only cases defined by two severity criteria had more CDID-related ICU admissions (18.8 vs. 0.0%) and higher CDID-related mortality (25.0 vs. 2.0%, p < 0.05) compared with cases defined by one criterion. Severe comorbidities and the continuation of concomitant antibiotics administered at CDID onset reduced (p < 0.05) the 30-day survival and increased (p = 0.053) 30-day all-cause mortality, with 57.6 vs. 10.7% and 52.0 vs. 25.0%, respectively. Conclusions: CDID treatment non-concordant with the guidelines was associated with various adverse outcomes. In CDID with leukocytes ≥ 15 × 109/L and serum creatinine level > 133 µmol/L (>1.5 mg/dL), enteral vancomycin should be used to avoid refractory response, as metronidazole use was associated with CDID-related ICU admission and CDID-related mortality. Severe comorbidities worsened the outcomes as they were associated with reduced 30-day survival. The continuation of concomitant antibiotic therapy increased 30-day all-cause mortality; thus, it needs to be reasonably justified, deescalated or stopped.
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Affiliation(s)
- Dalia Adukauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Rytis Mickus
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Asta Dambrauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Tomas Vanagas
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Agnė Adukauskaitė
- Department of Cardiology and Angiology, University Hospital of Innsbruck, 6020 Innsbruck, Austria;
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Burrell L, Williams R, ten Ham-Baloyi W. Clinical indications for plain abdominal radiographs: A survey study among radiographers. Health SA 2023; 28:2289. [PMID: 37670755 PMCID: PMC10476507 DOI: 10.4102/hsag.v28i0.2289] [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: 12/07/2022] [Accepted: 05/17/2023] [Indexed: 09/07/2023] Open
Abstract
Background Abdominal pain is a common complaint in the Emergency Department. Radiographers' knowledge and practices regarding clinical indications for performing abdominal examinations are crucial in the results radiographs produced. Aim To determine the knowledge and practices of radiographers regarding the clinical indications for performing radiographic examinations of the abdomen. Setting Four public hospitals in the Eastern Cape province, South Africa. Methods A cross-sectional study was conducted, using a convenience, all-inclusive sample of n = 85 radiographers. A hard copy self-administered questionnaire was distributed between February and June 2020. Descriptive (mean and standard deviations) and inferential (chi² test) statistics were generated using IBM® SPSS® version 26.0 software package. Results Knowledge of clinical indications had a mean of 59.41. All four demographics (age, years of experience, attended a short course and attended pattern recognition course) were significantly associated with overall knowledge. Additionally, short course attendance was significantly associated with most practice items, and two knowledge items (which views are done for perforation; and which view(s) demonstrate a stab abdomen). Pattern recognition was significantly associated with one knowledge item (which views are regarded as an acute abdomen). Conclusion Despite the lack of short courses and pattern recognition courses, radiographers' knowledge of clinical indications was good (>50%). Continuous training, accessible protocols for performing clinical indications for plain abdominal radiographic examinations for radiographers, audit, feedback and reminders to enhance protocol adherence are recommended. Contribution The study findings could be used to enhance knowledge and practices regarding clinical indications for plain abdominal radiographic examinations among radiographers.
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Affiliation(s)
- Lynn Burrell
- Department of Radiography, Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Razana Williams
- Department of Radiography, Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Wilma ten Ham-Baloyi
- Department of Nursing Science, Nelson Mandela University, Gqeberha, South Africa
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Rouleau G, Thiruganasambandamoorthy V, Wu K, Ghaedi B, Nguyen PA, Desveaux L. Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid Physicians in the Clinical Management of Patients With Syncope: Systematic Theoretical and User-Centered Design Approach. JMIR Hum Factors 2023; 10:e44089. [PMID: 37310783 DOI: 10.2196/44089] [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: 11/08/2022] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to improve syncope management in emergency department settings. Evidence-based tools often fail to have the intended impact because of suboptimal uptake or poor implementation. OBJECTIVE In this paper, we aimed to describe the process of developing evidence-based implementation strategies to support the deployment and use of the CSRS in real-world emergency department settings to improve syncope management among physicians. METHODS We followed a systematic approach for intervention development, including identifying who needs to do what differently, identifying the barriers and enablers to be addressed, and identifying the intervention components and modes of delivery to overcome the identified barriers. We used the Behaviour Change Wheel to guide the selection of implementation strategies. We engaged CSRS end users (ie, emergency medicine physicians) in a user-centered design approach to generate and refine strategies. This was achieved over a series of 3 qualitative user-centered design workshops lasting 90 minutes each with 3 groups of emergency medicine physicians. RESULTS A total of 14 physicians participated in the workshops. The themes were organized according to the following intervention development steps: theme 1-identifying and refining barriers and theme 2-identifying the intervention components and modes of delivery. Theme 2 was subdivided into two subthemes: (1) generating high-level strategies and developing strategies prototypes and (2) refining and testing strategies. The main strategies identified to overcome barriers included education in the format of meetings, videos, journal clubs, and posters (to address uncertainty around when and how to apply the CSRS); the development of a web-based calculator and integration into the electronic medical record (to address uncertainty in how to apply the CSRS); a local champion (to address the lack of team buy-in); and the dissemination of evidence summaries and feedback through email communications (to address a lack of evidence about impact). CONCLUSIONS The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure that the CSRS is well positioned for impact, a comprehensive suite of strategies was identified to address known barriers.
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Affiliation(s)
- Geneviève Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Nursing Department, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Kelly Wu
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Bahareh Ghaedi
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Phuong Anh Nguyen
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Karmelić E, Lindlöf H, Luckhaus JL, Castillo MM, Vicente V, Härenstam KP, Savage C. Decision-making on the fly: a qualitative study of physicians in out-of-hospital emergency medical services. BMC Emerg Med 2023; 23:65. [PMID: 37286931 DOI: 10.1186/s12873-023-00830-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/23/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Out-of-hospital Emergency Medical Services (OHEMS) require fast and accurate assessment of patients and efficient clinical judgment in the face of uncertainty and ambiguity. Guidelines and protocols can support staff in these situations, but there is significant variability in their use. Therefore, the aim of this study was to increase our understanding of physician decision-making in OHEMS, in particular, to characterize the types of decisions made and to explore potential facilitating and hindering factors. METHODS Qualitative interview study of 21 physicians in a large, publicly-owned and operated OHEMS in Croatia. Data was subjected to an inductive content analysis. RESULTS Physicians (mostly young, female, and early in their career), made three decisions (transport, treat, and if yes on either, how) after an initial patient assessment. Decisions were influenced by patient needs, but to a greater extent by factors related to themselves and patients (microsystem), their organization (mesosystem), and the larger health system (macrosystem). This generated a high variability in quality and outcomes. Participants desired support through further training, improved guidelines, formalized feedback, supportive management, and health system process redesign to better coordinate and align care across organizational boundaries. CONCLUSIONS The three decisions were made complex by contextual factors that largely lay outside physician control at the mesosystem level. However, physicians still took personal responsibility for concerns more suitably addressed at the organizational level. This negatively impacted care quality and staff well-being. If managers instead adopt a learning orientation, the path from novice to expert physician could be more ably supported through organizational demands and practices aligned with real-world practice. Questions remain on how managers can better support the learning needed to improve quality, safety, and physicians' journey from novice to expert.
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Affiliation(s)
- Ema Karmelić
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen, Stockholm, 18A 171 77, Sweden
| | - Henrik Lindlöf
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- The ambulance medical service of Region Västmanland, Västerås, Sweden
| | - Jamie Linnea Luckhaus
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen, Stockholm, 18A 171 77, Sweden
| | - Moa Malmqvist Castillo
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen, Stockholm, 18A 171 77, Sweden
| | - Veronica Vicente
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- The ambulance medical service in Stockholm (AISAB), Stockholm, Sweden
- Academic EMS, Stockholm, Sweden
| | - Karin Pukk Härenstam
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen, Stockholm, 18A 171 77, Sweden
- Department of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden
| | - Carl Savage
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen, Stockholm, 18A 171 77, Sweden.
- School of Health and Welfare, Halmstad University, Halmstad, Sweden.
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Ångerman S, Kirves H, Nurmi J. Multifaceted implementation and sustainability of a protocol for prehospital anaesthesia: a retrospective analysis of 2115 patients from helicopter emergency medical services. Scand J Trauma Resusc Emerg Med 2023; 31:21. [PMID: 37122004 PMCID: PMC10148755 DOI: 10.1186/s13049-023-01086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 04/18/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Prehospital emergency anaesthesia (PHEA) is a high-risk procedure. We developed a prehospital anaesthesia protocol for helicopter emergency medical services (HEMS) that standardises the process and involves ambulance crews as active team members to increase efficiency and patient safety. The aim of the current study was to evaluate this change and its sustainability in (i) on-scene time, (ii) intubation first-pass success rate, and (iii) protocol compliance after a multifaceted implementation process. METHODS The protocol was implemented in 2015 in a HEMS unit and collaborating emergency medical service systems. The implementation comprised dissemination of information, lectures, simulations, skill stations, academic detailing, and cognitive aids. The methods were tailored based on implementation science frameworks. Data from missions were gathered from mission databases and patient records. RESULTS During the study period (2012-2020), 2381 adults underwent PHEA. The implementation year was excluded; 656 patients were analysed before and 1459 patients after implementation of the protocol. Baseline characteristics and patient categories were similar. On-scene time was significantly redused after the implementation (median 32 [IQR 25-42] vs. 29 [IQR 21-39] minutes, p < 0.001). First pass success rate increased constantly during the follow-up period from 74.4% (95% CI 70.7-77.8%) to 97.6% (95% CI 96.7-98.3%), p = 0.0001. Use of mechanical ventilation increased from 70.6% (95% CI 67.0-73.9%) to 93.4% (95% CI 92.3-94.8%), p = 0.0001, and use of rocuronium increased from 86.4% (95% CI 83.6-88.9%) to 98.5% (95% CI 97.7-99.0%), respectively. Deterioration in compliance indicators was not observed. CONCLUSIONS We concluded that clinical performance in PHEA can be significantly improved through multifaceted implementation strategies.
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Affiliation(s)
- Susanne Ångerman
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Hetti Kirves
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Jouni Nurmi
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
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Bora AM, Piechotta V, Kreuzberger N, Monsef I, Wender A, Follmann M, Nothacker M, Skoetz N. The effectiveness of clinical guideline implementation strategies in oncology-a systematic review. BMC Health Serv Res 2023; 23:347. [PMID: 37024867 PMCID: PMC10080872 DOI: 10.1186/s12913-023-09189-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/15/2023] [Indexed: 04/08/2023] Open
Abstract
IMPORTANCE Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes. OBJECTIVE This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence. METHODS A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593. FINDINGS Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff. PATIENT-LEVEL Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain. PROVIDER-LEVEL Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain. CONCLUSIONS AND RELEVANCE Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.
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Affiliation(s)
- Ana-Mihaela Bora
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Vanessa Piechotta
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nina Kreuzberger
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Wender
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany, C/O Faculty of Medicine, Philipps University Marburg, Marburg, Germany
| | - Nicole Skoetz
- Evidence-Based Medicine, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Tewari P, Sweeney BF, Lemos JL, Shapiro L, Gardner MJ, Morris AM, Baker LC, Harris AS, Kamal RN. Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA Netw Open 2022; 5:e2231911. [PMID: 36112373 PMCID: PMC9482052 DOI: 10.1001/jamanetworkopen.2022.31911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. OBJECTIVE To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCE In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.
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Affiliation(s)
- Pariswi Tewari
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F. Sweeney
- Stanford University School of Medicine, Mountain View, California
| | - Jacie L. Lemos
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Arden M. Morris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Laurence C. Baker
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alex S. Harris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- VOICES Health Policy Research Center, Stanford University, Stanford, California
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Scheffler B, Schimböck F, Schöler A, Rösner K, Spallek J, Kopkow C. Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework. Front Neurol 2022; 13:828521. [PMID: 35968277 PMCID: PMC9363877 DOI: 10.3389/fneur.2022.828521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations. Materials and Methods This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed. Conclusion This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.
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Affiliation(s)
- Bettina Scheffler
- Department of Therapy Sciences I, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
| | - Florian Schimböck
- Department of Nursing Sciences and Clinical Nursing, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
| | - Almut Schöler
- Department of Therapy Sciences I, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
| | - Katrin Rösner
- Department of Health Sciences, University of Lübeck, Lübeck, Germany
| | - Jacob Spallek
- Department of Public Health, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
| | - Christian Kopkow
- Department of Therapy Sciences I, Brandenburg University of Technology Cottbus—Senftenberg, Senftenberg, Germany
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Knapp AA, Carroll AJ, Mohanty N, Fu E, Powell BJ, Hamilton A, Burton ND, Coldren E, Hossain T, Limaye DP, Mendoza D, Sethi M, Padilla R, Price HE, Villamar JA, Jordan N, Langman CB, Smith JD. A stakeholder-driven method for selecting implementation strategies: a case example of pediatric hypertension clinical practice guideline implementation. Implement Sci Commun 2022; 3:25. [PMID: 35256017 PMCID: PMC8900435 DOI: 10.1186/s43058-022-00276-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/19/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This article provides a generalizable method, rooted in co-design and stakeholder engagement, to identify, specify, and prioritize implementation strategies. To illustrate this method, we present a case example focused on identifying strategies to promote pediatric hypertension (pHTN) Clinical Practice Guideline (CPG) implementation in community health center-based primary care practices that involved meaningful engagement of pediatric clinicians, clinic staff, and patients/caregivers. This example was chosen based on the difficulty clinicians and organizations experience in implementing the pHTN CPG, as evidenced by low rates of guideline-adherent pHTN diagnosis and treatment. METHODS We convened a Stakeholder Advisory Panel (SAP), comprising 6 pediatricians and 5 academic partners, for 8 meetings (~12 h total) to rigorously identify determinants of pHTN CPG adherence and to ultimately develop a testable multilevel, multicomponent implementation strategy. Our approach expanded upon the Expert Recommendations for Implementation Change (ERIC) protocol by incorporating a modified Delphi approach, user-centered design methods, and the Implementation Research Logic Model (IRLM). At the recommendation of our SAP, we gathered further input from youth with or at-risk for pHTN and their caregivers, as well as clinic staff who would be responsible for carrying out facets of the implementation strategy. RESULTS First, the SAP identified 17 determinants, and 18 discrete strategies were prioritized for inclusion. The strategies primarily targeted determinants in the domains of intervention characteristics, inner setting, and characteristics of the implementers. Based on SAP ratings of strategy effectiveness, feasibility, and priority, three tiers of strategies emerged, with 7 strategies comprising the top tier implementation strategy package. Next, input from caregivers and clinic staff confirmed the feasibility and acceptability of the implementation strategies and provided further detail in the definition and specification of those strategies. CONCLUSIONS This method-an adaptation of the ERIC protocol-provided a pragmatic structure to work with stakeholders to efficiently identify implementation strategies, particularly when supplemented with user-centered design activities and the intuitive organizing framework of the IRLM. This generalizable method can help researchers identify and prioritize strategies that align with the implementation context with an increased likelihood of adoption and sustained use.
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Affiliation(s)
- Ashley A. Knapp
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Allison J. Carroll
- Department of Psychiatry and Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Nivedita Mohanty
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
- Alliance Chicago, Chicago, IL USA
| | - Emily Fu
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School & School of Medicine, Washington University in St. Louis, St. Louis, MO USA
| | - Alison Hamilton
- VA Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | | | | | | | | | | | | | | | - Heather E. Price
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Juan A. Villamar
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Neil Jordan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL USA
| | - Craig B. Langman
- Ann & Robert H. Lurie Children’s Hospital of Chicago and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Justin D. Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT USA
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Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study. Pediatr Qual Saf 2022; 7:e549. [PMID: 35369419 PMCID: PMC8970087 DOI: 10.1097/pq9.0000000000000549] [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] [Received: 08/10/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Although recommended, adolescent depression screening with appropriate initial management is challenging. This project aimed to improve adolescent depression screening rates during preventive care visits in 12 primary care clinics from 65.4% to 80%, increase the proportion of documented initial management for those with a positive screen from 69.5% to 85%, then sustain improvements for 12 months.
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15
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Stanley B, Collins L, Norman A, Bonomo A, Bonomo Y. Reducing opioid prescribing on discharge after orthopaedic surgery: does a guideline and education improve prescribing practice 1 year later? ANZ J Surg 2022; 92:1171-1177. [PMID: 35188322 DOI: 10.1111/ans.17557] [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: 03/25/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND An intervention Prescription Opioid Practice Improvement (POPI), addressing opioid prescribing on discharge following orthopaedic surgery, demonstrated improved practice. Here we report the sustainability of improved practice at 12 months, and the impact of a booster education intervention, POPI SOS (Safe Opioid Supply). METHODS Audits were performed using methodology described in previously published studies. RESULTS High proportion of patients were discharged on opioids, 89.9% 12 months post-POPI (n = 149) and 82.2% post-POPI SOS (n = 169). Twelve months post-POPI there was a significant reduction in combination immediate (IR) and slow release (SR) opioids, 45.7% at the end of POPI program to 34.3% at 12 months (χ2 (1, N = 364) = 4.47, ρ = 0.034); a significant decrease in opioid-weaning plans, 87.4% at the end of POPI program to 35.8% at 12 months (χ2 (1, N = 365) = 104.19, ρ = <0.001); and a significant increase in provision of full quantities of SR-opioids, 6.1% after the POPI program to 15.7% (χ2 (1, N = 364) = 8.95, ρ = 0.003). The POPI SOS booster program significantly improved measures including reduction in combination IR and SR, 34.3-22.3% (χ2 (1, N = 273) = 4.87, ρ = 0.028) and an increase in opioid plans in discharge summaries, from 35.8% to 77.7% (χ2 (1, N = 273) = 48.87, ρ < 0.001). CONCLUSION Better practice in relation to opioid prescribing is achievable but, for sustained improvement, opioid stewardship activities are needed to reduce the potential harms associated with prescription opioids.
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Affiliation(s)
- Beata Stanley
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Lisa Collins
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Amanda Norman
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Anthony Bonomo
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yvonne Bonomo
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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16
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Increasing Adherence to Acute Otitis Media Treatment Duration Guidelines using a Quality Improvement Approach. Pediatr Qual Saf 2021; 6:e501. [PMID: 34934881 PMCID: PMC8677959 DOI: 10.1097/pq9.0000000000000501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
This quality improvement initiative aimed to improve American Academy of Pediatrics acute otitis media (AOM) guideline adherence in pediatric urgent care sites by increasing the percentage of patients 2 years and older with AOM who received a short duration (7 days or fewer) of antibiotics from a baseline of 7% to a goal of 50%. METHODS This quality improvement initiative was conducted in a network of seven urgent care sites affiliated with a large academic children's hospital. The interventions focused on clinician and family education, clinical decision support, and a discharge template that defaulted to a 7-day duration of antibiotics for patients 2 years and older diagnosed with AOM. The outcome measure was the percentage of patients receiving 7 days or fewer of antibiotics. The process measure was the percentage of prescriptions originating from the new discharge template. A repeat visit for AOM within 30 days from the initial visit was the balancing measure. RESULTS The percentage of patients diagnosed with AOM receiving a short antibiotic course increased from a baseline of 7% to a new centerline mean of 67%, which exceeded the goal. This project resulted in 10,138 antibiotic days being avoided. Eighty-two percent of short-course prescriptions originated from the discharge template. Repeat visits for AOM within 1 month of the initial visit did not increase. CONCLUSIONS A quality improvement initiative combining education and clinical decision support improved adherence to AOM treatment duration guidelines and avoided unnecessary antibiotic exposure in a pediatric urgent care network without increasing treatment failures.
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17
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Mastenbrook J, Emrick D, Bauler LD, Markman J, Koedam T, Fales W. Evaluation of Basic Life Support First Responder Naloxone Administration Protocol Adherence. Cureus 2021; 13:e18932. [PMID: 34812316 PMCID: PMC8604552 DOI: 10.7759/cureus.18932] [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] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted. Methods: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence. Results: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30). Conclusion: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols.
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Affiliation(s)
- Joshua Mastenbrook
- Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
| | - Daniel Emrick
- Student Affairs, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
| | - Laura D Bauler
- Biomedical Sciences, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
| | - James Markman
- General Surgery, Mount Carmel Graduate Medical Education, Grove City, USA
| | - Tyler Koedam
- Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
| | - William Fales
- Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
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18
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Dmitriew C, Ohle R. Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome. Implement Sci Commun 2021; 2:60. [PMID: 34088362 PMCID: PMC8178923 DOI: 10.1186/s43058-021-00160-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. In order to facilitate the implementation of these recommendations, a clinical decision aid was created. The objective of this study was to identify barriers and facilitators among physicians prior to implementation of the guideline recommendations in a multicentre step wedge cluster randomized control trial. METHODS We conducted semi-structured interviews with nine emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to guideline recommendation uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified. RESULTS Two themes and six subthemes encompassing 13 theoretical domains were identified. These included clinical decision-making support, awareness of the evidence, social factors, expected consequences, ability of physicians to acquire the necessary data and ease of use. A majority of interviewees anticipated that the guideline recommendations would support clinical decision making and more effectively risk-stratify patients. Other facilitators included endorsement of the guidelines by professional organizations and peers. Barriers to implementation include the fact that laboratory testing and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the clinical decision aid and concerns about test specificity were also identified as potential barriers to use. CONCLUSION Physicians were amenable to using the AAS guideline recommendations to support clinical decision-making and to reduce resource use. A structured intervention should be developed to address the identified barriers and leverage the facilitators in order to ensure successful implementation. Our findings may have implications for the implementation of other guidelines used in emergency departments.
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Affiliation(s)
- Caitlin Dmitriew
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Robert Ohle
- The Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine, 41 Ramsey Lake Rd, Sudbury, ON, P3E 5 J1, Canada.
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19
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Sivakumar M, Gandhi A, Shakweh E, Li YM, Safinia N, Smith BC, Marshall A, Turner L, Mukhopadhya A, Haboubi HN, Vincent R, Tan HK, Alrubaiy L, Jones DEJ. Widespread gaps in the quality of care for primary biliary cholangitis in UK. Frontline Gastroenterol 2021; 13:32-38. [PMID: 34966531 PMCID: PMC8666861 DOI: 10.1136/flgastro-2020-101713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/12/2021] [Accepted: 01/26/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Primary biliary cholangitis (PBC) is a progressive, autoimmune, cholestatic liver disease affecting approximately 15 000 individuals in the UK. Updated guidelines for the management of PBC were published by The European Association for the Study of the Liver (EASL) in 2017. We report on the first national, pilot audit that assesses the quality of care and adherence to guidelines. DESIGN Data were collected from 11 National Health Service hospitals in England, Wales and Scotland between 2017 and 2020. Data on patient demographics, ursodeoxycholic acid (UDCA) dosing and key guideline recommendations were captured from medical records. Results from each hospital were evaluated for target achievement and underwent χ2 analysis for variation in performance between trusts. RESULTS 790 patients' medical records were reviewed. The data demonstrated that the majority of hospitals did not meet all of the recommended EASL standards. Standards with the lowest likelihood of being met were identified as optimal UDCA dosing, assessment of bone density and assessment of clinical symptoms (pruritus and fatigue). Significant variations in meeting these three standards were observed across UK, in addition to assessment of biochemical response to UDCA (all p<0.0001) and assessment of transplant eligibility in high-risk patients (p=0.0297). CONCLUSION Our findings identify a broad-based deficiency in 'real-world' PBC care, suggesting the need for an intervention to improve guideline adherence, ultimately improving patient outcomes. We developed the PBC Review tool and recommend its incorporation into clinical practice. As the first audit of its kind, it will be used to inform a future wide-scale reaudit.
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Affiliation(s)
- Mathuri Sivakumar
- Medicine, University of Birmingham, Birmingham, UK,Medicine, Imperial College London, London, UK
| | - Akash Gandhi
- Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Eathar Shakweh
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Yu Meng Li
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Niloufar Safinia
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Belinda Claire Smith
- Hepatology and Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Aileen Marshall
- Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Lucy Turner
- Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | - Ashis Mukhopadhya
- Gastroenterology, Grampian University Hospitals NHS Trust, Aberdeen, UK
| | | | - Rebecca Vincent
- Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Huey Kuan Tan
- Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Laith Alrubaiy
- Medicine, Imperial College London, London, UK,Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, London, UK
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20
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Gunnink LB, Arouri DJ, Jolink FE, Lokate M, de Jonge K, Kampmeier S, Kreis C, Raschke M, Kleinjan M, ter Maaten JC, Friedrich AW, Bathoorn E, Glasner C. Compliance to Screening Protocols for Multidrug-Resistant Microorganisms at the Emergency Departments of Two Academic Hospitals in the Dutch-German Cross-Border Region. Trop Med Infect Dis 2021; 6:tropicalmed6010015. [PMID: 33530494 PMCID: PMC7838951 DOI: 10.3390/tropicalmed6010015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/12/2022] Open
Abstract
Infections caused by multidrug-resistant organisms (MDROs) are associated with prolonged hospitalization and higher risk of mortality. Patients arriving in the hospital via the emergency department (ED) are screened for the presence of MDROs in compliance with the screening protocols in order to apply the correct isolation measures. In the Dutch–German border region, local hospitals apply their own screening protocols which are based upon national screening protocols. The contents of the national and local MDRO screening protocols were compared on vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing and carbapenem-resistant Enterobacteriaceae (CPE/CRE). The practicality of the screening protocols was evaluated by performing an audit. As a result, the content of the MDRO screening protocols differed regarding risk factors for MDRO carriage, swab site, personal protective equipment, and isolation measures. The observations and questionnaires showed that the practicality was sufficient; however, the responsibility was not designated clearly and education regarding the screening protocols was deemed inappropriate. The differences between the MDRO screening protocols complicate patient care in the Dutch–German border region. Arrangements have to be made about the responsibility of the MDRO screening, and improvements are necessary concerning education regarding the MDRO screening protocols.
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Affiliation(s)
- Lisa B. Gunnink
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Donia J. Arouri
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Floris E.J. Jolink
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Mariëtte Lokate
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Klaas de Jonge
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Stefanie Kampmeier
- Institute of Hygiene, University Hospital Münster, Robert-Koch-Straße 41, 48149 Münster, Germany;
| | - Carolin Kreis
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany; (C.K.); (M.R.)
| | - Michael Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany; (C.K.); (M.R.)
| | - Mirjam Kleinjan
- Department of Emergency Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Jan C. ter Maaten
- Department of Internal Medicine, Emergency Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Alex W. Friedrich
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Erik Bathoorn
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
| | - Corinna Glasner
- Department of Medical Microbiology and Infection Control, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (L.B.G.); (D.J.A.); (F.E.J.J.); (M.L.); (K.d.J.); (A.W.F.); (E.B.)
- Correspondence: ; Tel.: +31-(0)-50-36-13480
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Barriers to and Facilitators of Adherence to Clinical Practice Guidelines in the Middle East and North Africa Region: A Systematic Review. Healthcare (Basel) 2020; 8:healthcare8040564. [PMID: 33333843 PMCID: PMC7765264 DOI: 10.3390/healthcare8040564] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/19/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022] Open
Abstract
The current review aims to investigate the barriers to and facilitators of the adherence to clinical practice guidelines (CPGs) in the Middle East and North Africa (MENA) region. English language studies published between January 2010 and May 2019 were searched on PubMed, Embase, and EBSCO. The barriers were categorized as clinician-related factors, such as lack of awareness of familiarity with the CPGs, and external factors, such as patients, guidelines, and environmental factors. The search identified 295 titles, out of which 15 were included. Environmental factors, specifically lack of time, resources, incentives, availability, and costs of treatment or diagnostic tests, training, and dissemination plans were the most commonly identified barriers. The familiarity with or awareness of healthcare professionals about the guideline, guideline characteristics, lack of agreement with the guidelines and preference in clinical judgment, physician self-efficacy, and motivation were reported to a lesser extent. Few studies reported on the compliance of facilitators with the guidelines including disseminating and advertising guideline materials, education and training on the guidelines, regulatory and financial incentives, and support from institutions. The review highlights that the studies on barriers to and facilitators of compliance with CPGs in the MENA region are limited in number and quality.
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Höglund E, Andersson-Hagiwara M, Schröder A, Möller M, Ohlsson-Nevo E. Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden. BMC Emerg Med 2020; 20:61. [PMID: 32778074 PMCID: PMC7418316 DOI: 10.1186/s12873-020-00353-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/21/2020] [Indexed: 01/10/2023] Open
Abstract
Background There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data. Methods A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test. Results Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women. Conclusions Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.
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Affiliation(s)
- Erik Höglund
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
| | - Magnus Andersson-Hagiwara
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Agneta Schröder
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.,Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Gjøvik, Norway
| | - Margareta Möller
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden
| | - Emma Ohlsson-Nevo
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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23
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Cole JL. Gap Analysis for the Conversion to Area Under the Curve Vancomycin Monitoring in a Small Rural Hospital. Fed Pract 2020; 37:S12-S17. [PMID: 32704226 PMCID: PMC7373075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Consensus guidelines for vancomycin monitoring now recommend area under the curve (AUC) calculations for optimal vancomycin efficacy and safety. This will be a major practice change for many facilities. Implementation guidance is available but has not been reported in smaller, primary care hospitals. The objective of this study was to measure the uptake of AUC monitoring implementation in a rural facility. METHODS This is a gap analysis evaluating the appropriateness of vancomycin levels tests after the April 1, 2019 transition. All vancomycin levels between April 2019 and June 2019 after the go-live date were included with no exclusions in a retrospective chart review. The primary outcome was the proportion of levels in the appropriate time frame: peaks 1 to 2 hours after infusion with troughs at least 1 half-life after initial dose and prior to the next dose. Secondary outcomes included reasons identified for inappropriate levels and the proportion of AUC24 calculations within therapeutic range (400-600 mg.h/L). Descriptive statistics were used to measure the scope and outcomes of this transition. RESULTS The transition was effective with 97% of cases utilizing AUC-based methods. There were 65 vancomycin levels in the 3-month study period with 86% deemed appropriate. Of the 9 inappropriate levels, 4 had to be repeated for accurate monitoring. There were 28 two-level couplets used for AUC24 calculations, 17 (61%) fell within therapeutic range. CONCLUSION Implementation strategies for the AUC transition described in tertiary medical centers can be successfully utilized in primary facilities.
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Affiliation(s)
- Jennifer L Cole
- is a Clinical Pharmacy Specialist in Critical Care and Internal Medicine at Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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24
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Gad M, Salem A, Oortwijn W, Hill R, Godman B. Mapping of Current Obstacles for Rationalizing Use of Medicines (CORUM) in Europe: Current Situation and Potential Solutions. Front Pharmacol 2020; 11:144. [PMID: 32194401 PMCID: PMC7063972 DOI: 10.3389/fphar.2020.00144] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/04/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction There are increasing concerns regarding the inappropriate use of medicines with expenditure continuing to grow driven by increasing sales in oncology and orphan diseases, enhanced by their emotive nature. As a result, even high income countries are struggling to fund new premium priced medicines. These concerns have resulted in initiatives to better manage the entry of new medicines and enhance the rational use of medicines (RUM). However, there is a need to ascertain the current situation. We sought to address this by developing the Current Obstacles for Rationalizing Use of Medicines in Europe (CORUM) mapping tool to qualitatively investigate the current situation and provide analysis of current views on RUM and interventions among key European payers and their advisers. The findings will be used to provide future guidance. Methodology Descriptive study exploring and identifying perceived gaps to achieving optimal RUM. The CORUM tool was based on the WHO 12 key interventions to promote RUM. Results 62 participants took part with most respondents believing their country could improve RUM capacity. This included educational initiatives on the use of clinical guidelines (90%) and the inclusion of problem-based pharmacotherapy in undergraduate curricula and for Continued Professional Development. Key challenges included a lack of regular updates of guidelines, exacerbated by limited funding and a lack of follow-up to monitor adherence to agreed guidelines. RUM could also be enhanced by the development of regional formularies as well as implementing Drug and Therapeutic Committees where these are currently limited. There also needs to be greater co-ordination between RUM and Health Technology Assessment activities, with countries learning from each other. Conclusion There is an urgent need to improve RUM through improved educational and other activities among European countries, with countries learning from each other. This will involve addressing current challenges and we will be following this up.
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Affiliation(s)
- Mohamed Gad
- Global Health and Development Group, Imperial College London, London, United Kingdom
| | - Ahmed Salem
- Real World Evidence Solutions, IQVIA, Zaventem, Belgium
| | - Wija Oortwijn
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, United Kingdom
| | - Brian Godman
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Health Economics Centre, University of Liverpool Management School, Liverpool, United Kingdom.,Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa
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25
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Villarosa AR, Maneze D, Ramjan LM, Srinivas R, Camilleri M, George A. The effectiveness of guideline implementation strategies in the dental setting: a systematic review. Implement Sci 2019; 14:106. [PMID: 31847876 PMCID: PMC6918615 DOI: 10.1186/s13012-019-0954-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 11/25/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Guideline implementation has been an ongoing challenge in the dental practice setting. Despite this, there are no reviews summarising the existing evidence regarding effective guideline implementation strategies in this setting. In order to address this, this systematic review examines the effectiveness of guideline implementation strategies in the dental practice setting. METHODS A systematic search was undertaken according to the PRISMA statement across nine electronic databases, targeting randomised controlled trials and quasi-experimental studies which evaluated the effectiveness of guideline implementation strategies in improving guideline adherence in the dental setting. All records were independently examined for relevance and appraised for study quality by two authors, with consensus achieved by a third author. Data were extracted from included studies using a standardised data extraction pro forma. RESULTS A total of 15 records were eligible for inclusion in this review, which focused on the effects of audit and feedback, reminders, education, patient-mediated interventions, pay for performance and multifaceted interventions. Although there were some conflicting evidence, studies within each category of implementation strategy indicated a positive effect on guideline adherence. CONCLUSIONS This study has identified education, reminders and multifaceted interventions as effective implementation strategies for the dental practice setting. Although this is similar to research findings from other health sectors, there is some evidence to suggest patient-mediated interventions may be less effective and pay for performance may be more effective in the dental setting. These findings can inform policy makers, professional associations, colleges and organisations in the future adoption of clinical guidelines in the dental practice setting. TRIAL REGISTRATION This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration ID CRD42018093023.
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Affiliation(s)
- Amy R Villarosa
- Centre for Oral Health Outcomes and Research Translation (COHORT), Liverpool, 1871, Australia. .,Western Sydney University, Penrith, 2751, Australia. .,South Western Sydney Local Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia. .,Ingham Institute for Applied Medical Research, Liverpool, 1871, Australia.
| | - Della Maneze
- Centre for Oral Health Outcomes and Research Translation (COHORT), Liverpool, 1871, Australia.,Western Sydney University, Penrith, 2751, Australia.,South Western Sydney Local Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool, 1871, Australia
| | - Lucie M Ramjan
- Centre for Oral Health Outcomes and Research Translation (COHORT), Liverpool, 1871, Australia.,Western Sydney University, Penrith, 2751, Australia.,Ingham Institute for Applied Medical Research, Liverpool, 1871, Australia.,Translational Health Research Institute, Western Sydney University, Penrith, 2751, Australia
| | - Ravi Srinivas
- Centre for Oral Health Outcomes and Research Translation (COHORT), Liverpool, 1871, Australia.,Western Sydney University, Penrith, 2751, Australia.,South Western Sydney Local Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool, 1871, Australia.,University of Sydney, Camperdown, 2050, Australia
| | - Michelle Camilleri
- South Western Sydney Local Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
| | - Ajesh George
- Centre for Oral Health Outcomes and Research Translation (COHORT), Liverpool, 1871, Australia.,Western Sydney University, Penrith, 2751, Australia.,South Western Sydney Local Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, Liverpool, 1871, Australia.,Translational Health Research Institute, Western Sydney University, Penrith, 2751, Australia.,University of Sydney, Camperdown, 2050, Australia
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