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Mazzucca S, Tabak RG, Pilar M, Ramsey AT, Baumann AA, Kryzer E, Lewis EM, Padek M, Powell BJ, Brownson RC. Variation in Research Designs Used to Test the Effectiveness of Dissemination and Implementation Strategies: A Review. Front Public Health 2018. [PMID: 29515989 PMCID: PMC5826311 DOI: 10.3389/fpubh.2018.00032] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background The need for optimal study designs in dissemination and implementation (D&I) research is increasingly recognized. Despite the wide range of study designs available for D&I research, we lack understanding of the types of designs and methodologies that are routinely used in the field. This review assesses the designs and methodologies in recently proposed D&I studies and provides resources to guide design decisions. Methods We reviewed 404 study protocols published in the journal Implementation Science from 2/2006 to 9/2017. Eligible studies tested the efficacy or effectiveness of D&I strategies (i.e., not effectiveness of the underlying clinical or public health intervention); had a comparison by group and/or time; and used ≥1 quantitative measure. Several design elements were extracted: design category (e.g., randomized); design type [e.g., cluster randomized controlled trial (RCT)]; data type (e.g., quantitative); D&I theoretical framework; levels of treatment assignment, intervention, and measurement; and country in which the research was conducted. Each protocol was double-coded, and discrepancies were resolved through discussion. Results Of the 404 protocols reviewed, 212 (52%) studies tested one or more implementation strategy across 208 manuscripts, therefore meeting inclusion criteria. Of the included studies, 77% utilized randomized designs, primarily cluster RCTs. The use of alternative designs (e.g., stepped wedge) increased over time. Fewer studies were quasi-experimental (17%) or observational (6%). Many study design categories (e.g., controlled pre-post, matched pair cluster design) were represented by only one or two studies. Most articles proposed quantitative and qualitative methods (61%), with the remaining 39% proposing only quantitative. Half of protocols (52%) reported using a theoretical framework to guide the study. The four most frequently reported frameworks were Consolidated Framework for Implementing Research and RE-AIM (n = 16 each), followed by Promoting Action on Research Implementation in Health Services and Theoretical Domains Framework (n = 12 each). Conclusion While several novel designs for D&I research have been proposed (e.g., stepped wedge, adaptive designs), the majority of the studies in our sample employed RCT designs. Alternative study designs are increasing in use but may be underutilized for a variety of reasons, including preference of funders or lack of awareness of these designs. Promisingly, the prevalent use of quantitative and qualitative methods together reflects methodological innovation in newer D&I research.
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Affiliation(s)
- Stephanie Mazzucca
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Rachel G Tabak
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Meagan Pilar
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Alex T Ramsey
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Ana A Baumann
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Emily Kryzer
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Ericka M Lewis
- School of Social Work, University of Maryland, Baltimore, MD, United States
| | - Margaret Padek
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States.,Department of Surgery, Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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Reid K, Hartling L, Ali S, Le A, Norris A, Scott SD. Development and Usability Evaluation of an Art and Narrative-Based Knowledge Translation Tool for Parents With a Child With Pediatric Chronic Pain: Multi-Method Study. J Med Internet Res 2017; 19:e412. [PMID: 29242180 PMCID: PMC5746621 DOI: 10.2196/jmir.8877] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/12/2017] [Accepted: 10/29/2017] [Indexed: 11/26/2022] Open
Abstract
Background Chronic pain in childhood is increasingly being recognized as a significant clinical problem for children and their families. Previous research has identified that families want information about the causes of their child’s chronic pain, treatment options, and effective strategies to help their child cope with the pain. Unfortunately, parents have reported that finding this information can be challenging. Objective The aim of this study was to actively work together with children attending a pediatric chronic pain clinic and their parents to develop, refine, and evaluate the usability of an art and narrative-based electronic book (e-book) for pediatric chronic pain. Methods A multiphase, multi-method research design employing patient engagement techniques was used to develop, refine, and evaluate the usability of an art and narrative based e-book for pediatric chronic pain management to facilitate knowledge translation for parents with a child with chronic pain. The multiple phases included the following: (1) qualitative interviews to compile parents’ narratives using qualitative interviews; (2) qualitative data analysis; (3) development of an e-book prototype; (4) expert clinician feedback; (5) parent usability evaluation, knowledge change, and confidence in knowledge responses using an electronic survey; (6) e-book refinement; and (7) dissemination of the e-book. Results A 48-page e-book was developed to characterize the experiences of a family living with a child with chronic pain. The e-book was a composite narrative of the parent interviews and encompassed descriptions of the effects the condition has on each member of the family. This was merged with the best available research evidence on the day-to-day management of pediatric chronic pain. The e-book was vetted for clinical accuracy by expert pediatric pain clinicians. All parents that participated in the usability evaluation (N=14) agreed or strongly agreed the content of the e-book was easy to understand and stated that they would recommend the e-book to other families who have children with chronic pain. Our research identified up to a 21.4% increase in knowledge after using the e-book, and paired t tests demonstrated a statistically significant difference in confidence in answering two of the five knowledge questions (chronic pain is a disease involving changes in the nervous system; the use of ibuprofen is usually effective at controlling chronic pain); t13=0.165, P=.001 and t13=0.336, P=.002, respectively, after being exposed to the e-book. Conclusions Our results demonstrate that parents positively rated an e-book developed for parents with a child with chronic pain. Our results also identify that overall, parents’ knowledge increased after using the e-book, and confidence in their knowledge about chronic pain and its management increased in two aspects after e-book exposure. These results suggest that art and narrative-based knowledge translation interventions may be useful in transferring complex health information to parents.
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Affiliation(s)
- Kathy Reid
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.,Stollery Children's Hospital, Alberta Health Services, Edmonton, AB, Canada
| | - Lisa Hartling
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Samina Ali
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Anne Le
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Allison Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.,Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
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Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr 2017; 171:957-964. [PMID: 28828486 PMCID: PMC5710624 DOI: 10.1001/jamapediatrics.2017.2135] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes. OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis. EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTS Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCE The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Departments of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J. Farion
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne Beno
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - C. Michelle McTimoney
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada,Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Nadia Sourial
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark G. Roback
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis,Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
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Capnography Use During Intubation and Cardiopulmonary Resuscitation in the Pediatric Emergency Department. Pediatr Emerg Care 2017; 33:457-461. [PMID: 27455341 PMCID: PMC5259553 DOI: 10.1097/pec.0000000000000813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Capnography is indicated as a guide to assess and monitor both endotracheal intubation and cardiopulmonary resuscitation (CPR). Our primary objective was to determine the effect of the 2010 American Heart Association (AHA) guidelines on the frequency of capnography use during critical events in children in the emergency department (ED). Our secondary objective was to examine associations between patient characteristics and capnography use among these patients. METHODS A retrospective chart review was performed on children aged 0 to 21 years who were intubated or received CPR in 2 academic children's hospital EDs between January 2009 and December 2012. Age, sex, time of arrival, medical or traumatic cause, length of CPR, return of spontaneous circulation (ROSC), documented use of capnography and colorimetry, capnography values, and adverse events were recorded. RESULTS Two hundred ninety-two patients were identified and analyzed. Intubation occurred in 95% of cases and CPR in 30% of cases. Capnography was documented in only 38% of intubated patients and 13% of patients requiring CPR. There was an overall decrease in capnography use after publication of the 2010 AHA recommendations (P = 0.05). Capnography use was associated with a longer duration of CPR and return of spontaneous circulation. CONCLUSIONS Despite the 2010 AHA recommendations, a minority of critically ill children are being monitored with capnography and an unexpected decrease in documented use occurred among our sample. Further education and implementation of capnography should take place to improve the use of this monitoring device for critically ill pediatric patients in the ED.
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Cloutier RL, Mistry RD, Cico S, Merritt C, Lam SHF, Auerbach M, Skaugset LM, Klig J, Wolff M, Duong M, Walthall J. Keeping Up With the Kids: Diffusion of Innovation in Pediatric Emergency Medicine Among Emergency Physicians. Acad Emerg Med 2017; 24:769-775. [PMID: 28421650 DOI: 10.1111/acem.13185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert L. Cloutier
- Emergency Medicine and Pediatrics; Oregon Health & Science University; Portland OR
| | - Rakesh D. Mistry
- Pediatrics and Emergency Medicine; University of Colorado School of Medicine; Section of Emergency Medicine; Children's Hospital Colorado; Aurora CO
| | - Stephen Cico
- Clinical Emergency Medicine & Pediatrics; Indiana University School of Medicine; Riley Hospital for Children; Indianapolis IN
| | - Chris Merritt
- Emergency Medicine & Pediatrics; Alpert Medical School of Brown University; Providence RI
| | - Samuel H. F. Lam
- UC San Diego Medical Center/Rady Children's Hospital of San Diego; San Diego CA
| | - Marc Auerbach
- Pediatrics and Emergency Medicine; Yale University School of Medicine; New Haven CT
| | | | - Jean Klig
- Pediatrics, Harvard Medical School/Massachusetts General Hospital; Boston MA
| | - Meg Wolff
- Emergency Medicine and Pediatrics; University of Michigan Medical School; Ann Arbor MI
| | - Myto Duong
- Pediatric Emergency Medicine; Southern Illinois University; Carbondale IL
| | - Jennifer Walthall
- Departments of Pediatrics and Emergency Medicine; Indiana University School of Medicine; Riley Hospital for Children; Indianapolis IN
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Wilson CL, Johnson D, Oakley E. Knowledge translation studies in paediatric emergency medicine: A systematic review of the literature. J Paediatr Child Health 2016; 52:112-25. [PMID: 27062613 DOI: 10.1111/jpc.13074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/19/2015] [Accepted: 09/27/2015] [Indexed: 11/29/2022]
Abstract
AIM Systematic review of knowledge translation studies focused on paediatric emergency care to describe and assess the interventions used in emergency department settings. METHODS Electronic databases were searched for knowledge translation studies conducted in the emergency department that included the care of children. Two researchers independently reviewed the studies. RESULTS From 1305 publications identified, 15 studies of varied design were included. Four were cluster-controlled trials, two patient-level randomised controlled trials, two interrupted time series, one descriptive study and six before and after intervention studies. Knowledge translation interventions were predominantly aimed at the treating clinician, with some targeting the organisation. Studies assessed effectiveness of interventions over 6-12 months in before and after studies, and 3-28 months in cluster or patient level controlled trials. Changes in clinical practice were variable, with studies on single disease and single treatments in a single site showing greater improvement. CONCLUSIONS Evidence for effective methods to translate knowledge into practice in paediatric emergency medicine is fairly limited. More optimal study designs with more explicit descriptions of interventions are needed to facilitate other groups to effectively apply these procedures in their own setting.
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Affiliation(s)
- Catherine L Wilson
- Departments of Emergency Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - David Johnson
- Departments of Pediatrics and Physiology and Pharmacology, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ed Oakley
- Departments of Emergency Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Bhatt M, Roback MG, Joubert G, Farion KJ, Ali S, Beno S, McTimoney CM, Dixon A, Dubrovsky AS, Barrowman N, Johnson DW. The design of a multicentre Canadian surveillance study of sedation safety in the paediatric emergency department. BMJ Open 2015; 5:e008223. [PMID: 26024999 PMCID: PMC4452752 DOI: 10.1136/bmjopen-2015-008223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Procedural sedation and analgesia have become standard practice in paediatric emergency departments worldwide. Although generally regarded as safe, serious adverse events such as bradycardia, asystole, pulmonary aspiration, permanent neurological injury and death have been reported, but their incidence is unknown due to the infrequency of their occurrence and lack of surveillance of sedation safety. To improve our understanding of the safety, comparative effectiveness and variation in care in paediatric procedural sedation, we are establishing a multicentre patient registry with the goal of conducting regular and ongoing surveillance for adverse events in procedural sedation. METHODS This multicentre, prospective cohort study is enrolling patients under 18 years of age from six paediatric emergency departments across Canada. Data collection is fully integrated into clinical care and is performed electronically in real time by the healthcare professionals caring for the patient. The primary outcome is the proportion of patients who experience a serious adverse event as a result of their sedation. Secondary outcomes include the proportion of patients who experience an adverse event that could lead to a serious adverse event, proportion of patients who receive a significant intervention in response to an adverse event, proportion of patients who experience a successful sedation, and proportion of patients who experience a paradoxical reaction to sedation. There is no predetermined end date for data collection. ETHICS AND DISSEMINATION Ethics approval has been obtained from participating sites. Results will be disseminated using a multifaceted knowledge translation strategy by presenting at international conferences, publication in peer-reviewed journals, and through established networks.
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Affiliation(s)
- Maala Bhatt
- University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mark G Roback
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Gary Joubert
- Univeristy of Western Ontario, London, Ontario, Canada
- Children's Hospital of Western Ontario, London Health Science Centre, London, Ontario, Canada
| | - Ken J Farion
- University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Samina Ali
- University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Suzanne Beno
- University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - C Michelle McTimoney
- Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Center, Halifax, Nova Scotia, Canada
| | - Andrew Dixon
- University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Alexander Sasha Dubrovsky
- McGill University, Montreal, Québec, Canada
- Montreal Children's Hospital-McGill University Health Centre, Montreal, Québec, Canada
| | - Nick Barrowman
- University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - David W Johnson
- University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
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Langhan ML, Riera A, Kurtz JC, Schaeffer P, Asnes AG. Implementation of newly adopted technology in acute care settings: a qualitative analysis of clinical staff. J Med Eng Technol 2014; 39:44-53. [PMID: 25367721 DOI: 10.3109/03091902.2014.973618] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Technologies are not always successfully implemented into practice. This study elicited experiences of acute care providers with the introduction of technology and identified barriers and facilitators in the implementation process. A qualitative study using one-on-one interviews among a purposeful sample of 19 physicians and nurses within 10 emergency departments and intensive care units was performed. Grounded theory, iterative data analysis and the constant comparative method were used to inductively generate ideas and build theories. Five major categories emerged: decision-making factors, the impact on practice, technology's perceived value, facilitators and barriers to implementation. Barriers included negative experiences, age, infrequent use and access difficulties. A positive outlook, sufficient training, support staff and user friendliness were facilitators. This study describes strategies implicated in the successful implementation of newly adopted technology in acute care settings. Improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology.
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Affiliation(s)
- Melissa L Langhan
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine , New Haven, CT , USA and
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