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Wickbom F, Berghog W, Bernhardsson S, Persson L, Kunkel S, Undén J. Pediatric head injury guideline use in Sweden: a cross-sectional survey on determinants for successful implementation of a clinical practice guideline. BMC Health Serv Res 2024; 24:965. [PMID: 39169324 PMCID: PMC11340051 DOI: 10.1186/s12913-024-11423-z] [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: 03/16/2024] [Accepted: 08/09/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND The Scandinavian Neurotrauma Committee guideline (SNC-16) was developed and published in 2016, to aid clinicians in management of pediatric head injuries in Scandinavian emergency departments (ED). The objective of this study was to explore determinants for use of the SNC-16 guideline by Swedish ED physicians. METHODS This is a nationwide, cross-sectional, web-based survey in Sweden. Using modified snowball sampling, physicians managing children in the ED were invited via e-mail to complete the validated Clinician Guideline Determinants Questionnaire between February and May, 2023. Baseline data, data on enablers and barriers for use of the SNC-16 guideline, and preferred routes for implementation and access of guidelines in general were collected and analyzed descriptively and exploratory with Chi-square and Fisher's tests. RESULTS Of 595 invitations, 198 emergency physicians completed the survey (effective response rate 33.3%). There was a high reported use of the SNC-16 guideline (149/195; 76.4%) and a strong belief in its benefits for the patients (188/197; 95.4% agreement). Respondents generally agreed with the guideline's content (187/197; 94.9%) and found it easy to use and navigate (188/197; 95.4%). Some respondents (53/197; 26.9%) perceived a lack of organizational support needed to use the guideline. Implementation tools may be improved as only 58.9% (116/197) agreed that the guideline includes such. Only 37.6% (74/197) of the respondents agreed that the guideline clearly describes the underlying evidence supporting the recommendation. Most respondents prefer to consult colleagues (178/198; 89.9%) and guidelines (149/198; 75.3%) to gain knowledge to guide clinical decision making. Four types of enablers for guideline use emerged from free-text answers: ease of use and implementation, alignment with local guidelines and practice, advantages for stakeholders, and practicality and accessibility. Barriers for guideline use were manifested as: organizational challenges, medical concerns, and practical concerns. CONCLUSIONS The findings suggest high self-reported use of the SNC-16 guideline among Swedish ED physicians. In updated versions of the guideline, focus on improving implementation tools and descriptions of the underlying evidence may further facilitate adoption and adherence. Measures to improve organizational support for guideline use and involvement of patient representatives should also be considered.
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Affiliation(s)
- Fredrik Wickbom
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden.
- Lund University, Lund, Sweden.
| | - William Berghog
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden
| | - Susanne Bernhardsson
- Region Västra Götaland, Research, Education, Development, and Innovation Primary Health Care, Gothenburg, Sweden
- School of Public Health and Community Medicine, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Linda Persson
- Department of Orthopedics, Halland Hospital, Halmstad, Sweden
| | - Stefan Kunkel
- Department of Medicine, Växjö Hospital, Växjö, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden
- Lund University, Lund, Sweden
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Burgess L, Theobald KA, Kynoch K, Keogh S. Assessment of Barriers, Supports, and Context to Implement Best Practice Pain Management in the Emergency Department: The IMPAINED Study. Pain Manag Nurs 2024; 25:346-353. [PMID: 38825427 DOI: 10.1016/j.pmn.2024.03.010] [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: 09/14/2023] [Revised: 02/18/2024] [Accepted: 03/12/2024] [Indexed: 06/04/2024]
Abstract
AIM To assess the emergency department practice context and identify strategies to improve outcomes of patients with acute pain. BACKGROUND Effective treatment of acute pain in the emergency department depends upon clinicians adopting pain interventions into practice. However, it is well-recognized that acute pain is often undertreated. The local practice context strongly influences clinicians' adoption of interventions into their clinical practice. An assessment of this practice context can inform implementation interventions and strategies to improve outcomes for patients with acute pain. METHODS Chart audit, staff survey, and staff working groups were conducted from June 2020 to May 2021 Data were analyzed and synthesized across sources informed by assessment elements of the Ottawa model of research use (OMRU) implementation model and expert recommendations for implementing change strategies. RESULTS The OMRU facilitated contextual assessment of pain treatment practice in the emergency department and the development of implementation strategies. Adoption of evidence-based pain interventions was low in the sample studied. Workflow and workload were the primary barriers to evidence-based pain practices by potential adopters, while positive beliefs and high awareness of evidence-based pain interventions were supportive factors. Implementation strategies were informed by assessment findings and mapped to the Ottawa model and expert recommendations for implementing change elements. CONCLUSION The adoption of evidence into practice in the emergency department relies upon a comprehensive assessment of the local context. The use of the OMRU assessment process resulted in meaningful engagement with staff and a deeper understanding of local pain management practices. Clinicians view evidence-based pain management as important, however, there are competing priorities within the emergency department, such as patient flow and triage. This study provides an exemplar of utilizing an implementation framework to identify pain practices within the emergency department. CLINICAL IMPLICATIONS Achieving impactful change in clinical practice to improve patient outcomes should start with the application of implementation methods that enable comprehensive analysis of the local practice context. The assessment should begin with collaboration with local clinicians that persist throughout the life of the study to ensure change is sustainable.
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Affiliation(s)
- Luke Burgess
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Mater Health and Queensland Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence, Brisbane, Australia.
| | - Karen A Theobald
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Kate Kynoch
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Mater Health and Queensland Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence, Brisbane, Australia
| | - Samantha Keogh
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Centre for Healthcare Transformation, Queensland University of Tecchnology, Brisbane, Australia; Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
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3
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Chernick LS, Bugaighis M, Britton L, Cruz AT, Goyal MK, Mistry RD, Reed JL, Bakken S, Santelli JS, Dayan PS. Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis. Acad Emerg Med 2023; 30:99-109. [PMID: 36478023 DOI: 10.1111/acem.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED. METHODS In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives. RESULTS We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP. CONCLUSIONS The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.
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Affiliation(s)
- Lauren S Chernick
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Population and Family Health, Columbia University, New York, New York, USA
| | - Mona Bugaighis
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Laura Britton
- Department of Nursing, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea T Cruz
- Divisions of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Rakesh D Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, Cincinnati, USA
| | - Suzanne Bakken
- Department of Nursing and Bioinformatics, Columbia University Irving Medical Center, New York, New York, USA
| | - John S Santelli
- Department of Population and Family Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
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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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5
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Noehammer E, Ponweiser M, Romeyke T, Eibinger F. Benefits, Barriers and Determinants of Clinical Pathway Use in Germany, Austria and Switzerland. A pilot study. Health Serv Manage Res 2022; 36:119-126. [PMID: 35771177 PMCID: PMC10080374 DOI: 10.1177/09514848221107485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Performance-oriented financing of healthcare aims at demand-based and efficient resource allocation. Often, clinical pathways (CPs) are introduced in this context. PURPOSE For CP success (a) the degree of utilization of and divergence, (b) cost effects and (c) health professionals' acceptance rate of and satisfaction are relevant. There are gaps in research regarding these issues in general, and more specifically in the German speaking part of Europe. METHODOLOGY/APPROACH Employing a two-stage mixed-methods pilot study, we studied (a) and (b) quantitatively in Germany, Austria, and Switzerland, and (c) qualitatively in Germany and Austria. RESULTS Many hospitals already implemented CPs, but the utilization varies. They are expected to yield middle-range savings, but intangible benefits are more important. In general, employees are in favor of CPs, but several conditions need to be met, e.g. adaptability to local requirements. CONCLUSION Linking the results to the Consolidated Framework for Implementation Research showed many criteria are covered, which might lead to the positive evaluations, but also highlights the complexity of the intervention. PRACTICE IMPLICATION As enhanced acceptance rates are expected to lead to higher benefits and vice versa, management team should safeguard employee participation and perceived benefits in all phases of the CP cycle.
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Affiliation(s)
- Elisabeth Noehammer
- Department for Public Health, Health Services Research and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Austria
| | - Matthias Ponweiser
- Department for Public Health, Health Services Research and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Austria
| | - Tobias Romeyke
- Department for Public Health, Health Services Research and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Austria
| | - Florian Eibinger
- Department for Public Health, Health Services Research and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Austria
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Harley A, Schlapbach LJ, Lister P, Massey D, Gilholm P, Johnston ANB. Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study. BMC Health Serv Res 2021; 21:1161. [PMID: 34702256 PMCID: PMC8547904 DOI: 10.1186/s12913-021-07128-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Background Several health care systems internationally have implemented protocolised sepsis recognition and treatment bundles for children to improve outcomes, as recommended by the Surviving Sepsis Campaign. Successful implementation of clinical pathways is challenging and dependent on nurse engagement. There is limited data on knowledge translation during implementation of sepsis quality improvement programs. Methods This cross-sectional, multicentre observational survey study evaluated knowledge and perceptions of Emergency Department nurses in relation to the recognition, escalation and management of paediatric sepsis following implementation of a sepsis pathway. The study was conducted between September 2019 and March 2020 across 14 Emergency Departments in Queensland, Australia. The primary outcome was a sepsis knowledge score. An exploratory factor analysis was conducted to identify factors impacting nurses’ perceptions of recognition, escalation and management of paediatric sepsis and their association with knowledge. Using a logistic mixed effects model we explored associations between knowledge, identified factors and other clinical, demographic and hospital site variables. Results In total, 676 nurses responded to the survey and 534 were included in the analysis. The median knowledge score was 57.1% (IQR = 46.7–66.7), with considerable variation observed between sites. The exploratory factor analysis identified five factors contributing to paediatric sepsis recognition, escalation and management, categorised as 1) knowledge and beliefs, 2) social influences, 3) beliefs about capability and skills delivering treatment, 4) beliefs about capability and behaviour and 5) environmental context. Nurses reported strong agreement with statements measuring four of the five factors, responding lowest to the factor pertaining to capability and skills delivering treatment for paediatric sepsis. The factors knowledge and beliefs, capability and skills, and environmental context were positively associated with a higher knowledge score. Years of paediatric experience and dedicated nurse funding for the sepsis quality improvement initiative were also associated with a higher knowledge score. Conclusion Translation of evidence to practice such as successful implementation of a sepsis care bundle, relies on effective education of staff and sustained uptake of protocols in daily practice. Our survey findings identify key elements associated with enhanced knowledge including dedicated funding for hospitals to target paediatric sepsis quality improvement projects. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07128-2.
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Affiliation(s)
- Amanda Harley
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia. .,Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia. .,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia.,Pediatric and Neonatal Intensive Care Unit, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Paula Lister
- Paediatric Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.,School of Medicine, Griffith University, Brisbane, QLD, Australia
| | - Debbie Massey
- School of Nursing and Midwifery, Southern Cross University, Gold Coast, QLD, Australia
| | - Patricia Gilholm
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, QLD, Brisbane, Australia
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia.,Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
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7
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Curtis K, Kourouche S, Asha S, Considine J, Fry M, Middleton S, Mitchell R, Munroe B, Shaban RZ, D’Amato A, Skinner C, Wiseman G, Buckley T. Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation. PLoS One 2021; 16:e0256027. [PMID: 34618825 PMCID: PMC8496821 DOI: 10.1371/journal.pone.0256027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/28/2021] [Indexed: 12/03/2022] Open
Abstract
Background Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. Methods This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. Results There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period. Conclusion The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. Trial registration ANZCTR: ACTRN12618001548224, approved 17/09/2018
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
- * E-mail:
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Stephen Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia
- St George Clinical School, Faculty of Medicine, University of New South Wales, Kogarah, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Experience–Eastern Health Partnership, Box Hill, VIC, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Northern Sydney Local Health District, Hornsby, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne, Fitzroy, Australia
- Australian Catholic University, Sydney, NSW, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
| | - Ramon Z. Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
- Division of Infectious Diseases and Sexual Health, Department of Infection Prevention and Control, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
- New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Warwick Farm, NSW, Australia
| | - Alfa D’Amato
- NSW Activity Based Funding Taskforce, NSW Ministry of Health, Sydney, Australia
| | - Clare Skinner
- Emergency Department, Hornsby Ku-ring-ai Hospital, Hornsby, NSW, Australia
| | - Glen Wiseman
- Emergency Services, Canterbury Hospital, Campsie, NSW, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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8
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Sugalski AJ, Lo T, Beauchemin M, Grimes AC, Robinson PD, Walsh AM, Santesso N, Dang H, Fisher BT, Wrightson AR, Yu LC, Sung L, Dupuis LL. Facilitators and barriers to clinical practice guideline-consistent supportive care at pediatric oncology institutions: a Children's Oncology Group study. Implement Sci Commun 2021; 2:106. [PMID: 34530933 PMCID: PMC8447588 DOI: 10.1186/s43058-021-00200-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/25/2021] [Indexed: 11/27/2022] Open
Abstract
Background Clinical practice guideline (CPG)-consistent care improves patient outcomes, but CPG implementation is poor. Little is known about CPG implementation in pediatric oncology. This study aimed to understand supportive care CPG implementation facilitators and barriers at pediatric oncology National Cancer Institute (NCI) Community Oncology Research Program (NCORP) institutions. Methods Healthcare professionals at 26 pediatric, Children's Oncology Group-member, NCORP institutions were invited to participate in face-to-face focus groups. Serial focus groups were held until saturation of ideas was reached. Supportive care CPG implementation facilitators and barriers were solicited using nominal group technique (NGT), and implementation of specific supportive care CPG recommendations was discussed. Notes from each focus group were analyzed using a directed content analysis. The top five themes arising from an analysis of NGT items were identified, first from each focus group and then across all focus groups. Results Saturation of ideas was reached after seven focus groups involving 35 participants from 18 institutions. The top five facilitators of CPG implementation identified across all focus groups were organizational factors including charging teams with CPG implementation, individual factors including willingness to standardize care, user needs and values including mentorship, system factors including implementation structure, and implementation strategies including a basis in science. The top five barriers of CPG implementation identified were organizational factors including tolerance for inconsistencies, individual factors including lack of trust, system factors including administrative hurdles, user needs and values including lack of inclusivity, and professional including knowledge gaps. Conclusions Healthcare professionals at pediatric NCORP institutions believe that organizational factors are the most important determinants of supportive care CPG implementation. They believe that CPG-consistent supportive care is most likely to be delivered in organizations that prioritize evidence-based care, provide structure and resources to implement CPGs, and eliminate implementation barriers. Trial registration ClinicalTrials.gov Identifier: NCT02847130. Date of registration: July 28, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00200-2.
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Affiliation(s)
- Aaron J Sugalski
- University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Tammy Lo
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, USA
| | | | - Allison C Grimes
- University of Texas Health Science Center at San Antonio, San Antonio, USA
| | | | - Alexandra M Walsh
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, USA.,University of Arizona, Phoenix, USA
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ha Dang
- Children's Oncology Group, Monrovia, USA.,Department of Population and Public Health Sciences, University of Southern California, Los Angeles, USA
| | - Brian T Fisher
- Pediatrics and Epidemiology, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Andrea Rothfus Wrightson
- Clinical Research Nurse Coordinator, Nemours Center for Cancer and Blood Disorders, Wilmington, USA
| | - Lolie C Yu
- LSUHSC/Children's Hospital, New Orleans, USA
| | - Lillian Sung
- Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - L Lee Dupuis
- Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
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9
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Kourouche S, Curtis K, Munroe B, Asha SE, Carey I, Considine J, Fry M, Lyons J, Middleton S, Mitchell R, Shaban RZ, Unsworth A, Buckley T. Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation. Aust Crit Care 2021; 35:113-122. [PMID: 34144864 DOI: 10.1016/j.aucc.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. OBJECTIVE The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. METHODS This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. RESULTS/FINDINGS Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). CONCLUSIONS High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.
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Affiliation(s)
- Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia; Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia.
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia.
| | - Stephen Edward Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia; St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Ian Carey
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Experience - Eastern Health Partnership, Box Hill, VIC, Australia.
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney Faculty of Health, NSW, Australia; Northern Sydney Local Health District, NSW, Australia.
| | - Jack Lyons
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, NSW Australia.
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113.
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW 2006, Australia; Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia.
| | - Annalise Unsworth
- South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, NSW 2006, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
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10
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Dwyer M, Peterson GM, Gall S, Francis K, Ford KM. Health care providers' perceptions of factors that influence the provision of acute stroke care in urban and rural settings: A qualitative study. SAGE Open Med 2020; 8:2050312120921088. [PMID: 32435489 PMCID: PMC7223863 DOI: 10.1177/2050312120921088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/26/2020] [Indexed: 01/19/2023] Open
Abstract
Objectives Individuals living in rural areas have comparatively less access to acute stroke care than their urban counterparts. Understanding the local barriers and facilitators to the use of current best practice for acute stroke may inform efforts to reduce this disparity. Methods A qualitative study featuring semi-structured interviews and focus groups was conducted in the Australian state of Tasmania. Clinical staff from a range of disciplines involved in acute stroke care were recruited from three of the state's four major public hospitals (one urban and two rural). A semi-structured interview guide based on the findings of an earlier quantitative study was used to elicit discussion about the barriers and facilitators associated with providing acute stroke care. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set. Results Two focus groups and five individual interviews were conducted. Four major themes were identified from analysis of the data: systemic issues, clinician factors, additional support and patient-related factors. Acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less comprehensive, and often constrained by an absence of infrastructure or poor access to existing resources. Conclusion The identified factors help to characterise acute stroke care within urban and rural hospitals and will assist quality improvement efforts in Tasmania's hospitals.
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Affiliation(s)
- Mitchell Dwyer
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | | | - Seana Gall
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | - Karen Francis
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | - Karen M Ford
- Tasmanian Health Service, Hobart, TAS, Australia
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11
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Sampson FC, O'Cathain A, Goodacre S. How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments. Emerg Med J 2019; 37:85-94. [PMID: 31831588 DOI: 10.1136/emermed-2019-208994] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Inadequate pain management in EDs is a worldwide problem, yet there has been little progress in understanding how pain management can be improved. There is only weak evidence and limited rationale to support interventions to improve pain management. We used naturalistic, qualitative methods to understand the factors that influence how pain is managed within the adult ED. METHODS We used a multiple case study design incorporating 143-hour non-participant observation, documentary analysis and semistructured interviews with 37 staff and 19 patients at three EDs in the North of England between 2014 and 2016. We analysed data using thematic analysis. RESULTS Our analysis demonstrated that pain management was not well aligned with the core priorities of the ED and was overlooked when other works took priority. We identified that (1) pain management was not perceived to be a key organisational priority for which staff were held accountable and staff had limited awareness of their performance, (2) pain management was not a core component of ED education and training, (3) ED processes and structures were not aligned with pain management and pain reassessment was overlooked unless staff escalated pain management outside of normal processes and (4) staff held embedded beliefs that conceptualised pain management as distinct from core priorities and limited their capacity to improve. However, EDs were able to improve pain management by aligning processes of pain management with other core works, particularly patient flow (eg, nurse-initiated analgesia at triage). IMPLICATIONS EDs may be able to improve pain management by ensuring pain management processes align with key ED priorities. Undertaking multifaceted changes to structures and processes may enable staff to improve pain management and develop a culture in which pain management can be prioritised more easily. Future interventions need to be compatible with the wider work of the ED and enable patient flow in order to be adopted and maintained.
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12
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Koopmans E, Black T, Newton A, Dhugga G, Karduri N, Doan Q. Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth. Paediatr Child Health 2019; 24:359-365. [PMID: 31528104 DOI: 10.1093/pch/pxz038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 02/19/2019] [Accepted: 03/02/2019] [Indexed: 01/20/2023] Open
Abstract
Background This article describes the provincial dissemination of HEARTSMAP, an evidence-based emergency department (ED) psychosocial assessment and disposition decision tool for clinician use with children and youth. Methods HEARTSMAP was disseminated in partnership with local, child and youth mental health teams, as part of a quality improvement initiative implemented in British Columbia EDs. The target audience of education sessions were clinicians working in ED settings responsible for paediatric psychosocial assessments. We used the RE-AIM framework to evaluate the reach, effectiveness, adoption, implementation, and maintenance of HEARTSMAP dissemination, analyzing data from session evaluation forms and online tool data. Results Education sessions reached 475 attendees, in 52 of 95 British Columbia EDs. HEARTSMAP training was well received by clinicians with 96% describing effective content including increased comfort in conducting paediatric psychosocial assessments and confidence in disposition planning after training. Clinicians identified unclear processes and lack of local resources as the main barriers to implementation. One-third of the attendees expressed willingness to use the tool, and 27% of registered clinicians have used the tool postimplementation. Conclusions Our approach reached and effectively trained clinicians from over half of the province's EDs to use HEARTSMAP for emergency paediatric psychosocial assessments. For some, this provided greater comfort and confidence for these assessments and the following disposition decisions. This evaluation provides valuable insights on training clinicians to use a paediatric mental health tool within diverse ED settings and emphasized the need for ongoing support and institutional engagement to facilitate local, infrastructural, and operational processes for adoption and maintenance, postdissemination.
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Affiliation(s)
- Erica Koopmans
- BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Tyler Black
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | - Amanda Newton
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Gurm Dhugga
- BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Naveen Karduri
- BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Quynh Doan
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.,BC Children's Hospital Research Institute, Vancouver, British Columbia
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13
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Kourouche S, Buckley T, Van C, Munroe B, Curtis K. Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study. BMC Health Serv Res 2019; 19:461. [PMID: 31286954 PMCID: PMC6615309 DOI: 10.1186/s12913-019-4177-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. Aim To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. Methods 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. Results One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term ‘care bundle’ (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. Conclusions Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway. Electronic supplementary material The online version of this article (10.1186/s12913-019-4177-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Kourouche
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.
| | - Tom Buckley
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Connie Van
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Belinda Munroe
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Kate Curtis
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
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14
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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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15
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A scoping review describes methods used to identify, prioritize and display gaps in health research. J Clin Epidemiol 2019; 109:99-110. [PMID: 30708176 DOI: 10.1016/j.jclinepi.2019.01.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/10/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Different methods to examine research gaps have been described, but there are still no standard methods for identifying, prioritizing, or reporting research gaps. This study aimed to describe the methods used to identify, prioritize, and display gaps in health research. METHODS A scoping review using the Arksey and O'Malley methodological framework was carried out. We included all study types describing or reporting on methods to identify, prioritize, and display gaps or priorities in health research. Data synthesis is both quantitative and qualitative. RESULTS Among 1,938 identified documents, 139 articles were selected for analysis; 90 (65%) aimed to identify gaps, 23 (17%) aimed to determine research priorities, and 26 (19%) had both aims. The most frequent methods in the review were aimed at gap identification and involved secondary research, which included knowledge synthesis (80/116 articles, 69%), specifically systematic reviews and scoping reviews (58/80, 73%). Among 49 studies aimed at research prioritization, the most frequent methods were both primary and secondary research, accounting for 24 (49%) reports. Finally, 52 (37%) articles described methods for displaying gaps and/or priorities in health research. CONCLUSION This study provides a mapping of different methods used to identify, prioritize, and display gaps or priorities in health research.
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16
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Jabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci 2018; 13:139. [PMID: 30419942 PMCID: PMC6233585 DOI: 10.1186/s13012-018-0832-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. METHODS This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel. RESULTS Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. CONCLUSIONS Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. TRIAL REGISTRATION ClinicalTrials.gov, NCT01815710 .
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Affiliation(s)
- Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room W1415, Ottawa, ON, K1H 8L1, Canada.
- University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Amanda S Newton
- Department of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Johnson
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
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17
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Review of implementation strategies to change healthcare provider behaviour in the emergency department. CAN J EMERG MED 2018; 20:453-460. [PMID: 29429430 DOI: 10.1017/cem.2017.432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments. METHODS A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies. RESULTS We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research. CONCLUSIONS We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.
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18
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Roberts N, Hooper G, Lorencatto F, Storr W, Spivey M. Barriers and facilitators towards implementing the Sepsis Six care bundle (BLISS-1): a mixed methods investigation using the theoretical domains framework. Scand J Trauma Resusc Emerg Med 2017; 25:96. [PMID: 28927439 PMCID: PMC5606082 DOI: 10.1186/s13049-017-0437-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background The ‘Sepsis 6’, a care bundle of basic, but vital, measures (e.g. intravenous fluid, antibiotics) has been implemented to improve sepsis treatment. However, uptake has been variable. Tools from behavioral sciences, such as the Theoretical Domains Framework (TDF) may be used to understand and address such implementation issues. This study used a behavioral science approach to identify barriers and facilitators towards Sepsis Six implementation at a case study hospital. Methods Semi-structured interviews based on the TDF were conducted with a sample group of consultants, junior doctors and nurses from Emergency Department, Medical and Surgical Admissions, to explore barriers/facilitators to Sepsis Six performance. Transcripts were analyzed following the combined principles of content and framework analysis. Emerging themes informed a questionnaire to explore generalizability and importance across a sample of 261 stakeholders. Median importance and agreement ratings for each theme were calculated overall and for each role and clinical area. These were used to identify important barriers and important facilitators as targets for performance improvement. Results No new belief statements were discovered and data saturation was deemed achieved after 10 interviews. 1699 utterances were coded into 64 belief statements, then collated into a 51-item questionnaire. 113 questionnaire responses were obtained (44.3% response rate). Important barriers included insufficient audit and feedback, poor teamwork and communication, concerns about using the Sepsis Six in certain patients, insufficient training, and resource concerns. Facilitators included confidence in knowledge and skills, beliefs in overall benefits of the bundle, beliefs that identification and management of septic patients fell within everyone’s role, and that regular use of the bundle made it easier to remember. Some beliefs were applicable for the entire group, others were specific to particular staff groups. Discussion and Conclusions A range of barriers and facilitators towards Sepsis Six performance across different staff groups were systematically identified using a theoretically-informed approach. This can inform development of targeted performance improvement interventions. Electronic supplementary material The online version of this article (10.1186/s13049-017-0437-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neil Roberts
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK.
| | - Guy Hooper
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK
| | - Fabiana Lorencatto
- Centre for Health Services Research and Management, School of Health Sciences, City University of London, London, UK
| | - Wendell Storr
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK
| | - Michael Spivey
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK
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Roberts N, Lorencatto F, Manson J, Brundage SI, Jansen JO. What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework. Scand J Trauma Resusc Emerg Med 2016; 24:30. [PMID: 26968161 PMCID: PMC4788933 DOI: 10.1186/s13049-016-0226-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 03/10/2016] [Indexed: 02/03/2023] Open
Abstract
Background Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. Methods The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. Results and discussion 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. Conclusions This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0226-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neil Roberts
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Fabiana Lorencatto
- Division of Health Services Research and Management, School of Health Sciences, City University London, London, UK
| | - Joanna Manson
- Barts Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Susan I Brundage
- Barts Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jan O Jansen
- Departments of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary & Health Services Research Unit, University of Aberdeen, Ward 505, Aberdeen, UK.
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