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Hsu TH, Huang WC, Lin KC, Huang CL, Tai HY, Tsai YC, Wu MC, Chang YT. Impact of a targeted temperature management quality improvement project on survival and neurologic outcomes in cardiac arrest patients. J Chin Med Assoc 2023; 86:672-681. [PMID: 37220417 DOI: 10.1097/jcma.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) is recommended for postresuscitation care of patients with sudden cardiac arrest (SCA) and its implementation remains challenging. This study aimed to evaluate the newly designed Quality Improvement Project (QIP) to improve the quality of TTM and outcomes of patients with SCA. METHODS Patients who experienced out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) with return of spontaneous circulation (ROSC) and were treated in our hospital between January 2017 and December 2019 were enrolled retrospectively. All included patients received QIP intervention initiated as follows: (1) Protocols and standard operating procedures were created for TTM; (2) shared decision-making was documented; (3) job training instruction was created; and 4) lean medical management was implemented. RESULTS Among 248 included patients, the postintervention group (n = 104) had shorter duration of ROSC to TTM than the preintervention group (n = 144) (356 vs 540 minutes, p = 0.042); better survival rate (39.4% vs 27.1%, p = 0.04), and neurologic performance (25.0% vs 17.4%, p < 0.001). After propensity score matching (PSM), patients who received TTM (n = 48 ) had better neurologic performance than those without TTM (n = 48) (25.1% vs 18.8%, p < 0.001). OHCA (odds ratio [OR] = 2.705, 95% CI: 1.657-4.416), age >60 (OR = 2.154, 95% CI: 1.428-3.244), female (OR = 1.404, 95% CI: 1.005-1.962), and diabetes mellitus (OR = 1.429, 95% CI: 1.019-2.005) were negative predictors of survival; while TTM (OR = 0.431, 95% CI: 0.266-0.699) and bystander cardiopulmonary resuscitation (CPR) (OR=0.589, 95% CI: 0.35-0.99) were positive predictors. Age >60 (OR= 2.292, 95% CI: 1.58-3.323) and OHCA (OR= 2.928, 95% CI: 1.858-4.616) were negative predictors of favorable neurologic outcomes; while bystander CPR (OR=0.572, 95% CI: 0.355-0.922) and TTM (OR=0.457, 95% CI: 0.296-0.705) were positive predictors. CONCLUSION A new QIP with defined protocols, documented shared decision-making, and medical management guidelines improves TTM execution, duration from ROSC to TTM , survival, and neurologic outcomes of cardiac arrest patients.
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Affiliation(s)
- Thung-Hsien Hsu
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Chieh-Ling Huang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Hsiao-Yun Tai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ching Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Meng-Chen Wu
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Yun-Te Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, ROC
- Department of Emergency & Critical Care Medicine, Pingtung Veterans General Hospital, Pingtung, Taiwan, ROC
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Pantoja T, Grimshaw JM, Colomer N, Castañon C, Leniz Martelli J. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev 2019; 12:CD001174. [PMID: 31858588 PMCID: PMC6923326 DOI: 10.1002/14651858.cd001174.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.
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Affiliation(s)
- Tomas Pantoja
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nathalie Colomer
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Carla Castañon
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Javiera Leniz Martelli
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
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Ho AMH, Phelan R, Mizubuti GB, Murdoch JAC, Wickett S, Ho AK, Shyam V, Gilron I. Bias in Before-After Studies: Narrative Overview for Anesthesiologists. Anesth Analg 2019; 126:1755-1762. [PMID: 29239959 DOI: 10.1213/ane.0000000000002705] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Before-after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before-after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test-retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before-after studies.
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Affiliation(s)
- Anthony M H Ho
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachel Phelan
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - John A C Murdoch
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Wickett
- Bracken Health Sciences Library, Queen's University, Kingston, Ontario, Canada
| | - Adrienne K Ho
- City Hospital and Queen's Medical Center, Nottingham, United Kingdom
| | - Vidur Shyam
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ian Gilron
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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Patient and hospital factors predict use of coronary angiography in out-of-hospital cardiac arrest patients. Resuscitation 2019; 138:182-189. [DOI: 10.1016/j.resuscitation.2019.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/22/2019] [Accepted: 03/04/2019] [Indexed: 11/18/2022]
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Handley MA, Lyles CR, McCulloch C, Cattamanchi A. Selecting and Improving Quasi-Experimental Designs in Effectiveness and Implementation Research. Annu Rev Public Health 2018; 39:5-25. [PMID: 29328873 PMCID: PMC8011057 DOI: 10.1146/annurev-publhealth-040617-014128] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Interventional researchers face many design challenges when assessing intervention implementation in real-world settings. Intervention implementation requires holding fast on internal validity needs while incorporating external validity considerations (such as uptake by diverse subpopulations, acceptability, cost, and sustainability). Quasi-experimental designs (QEDs) are increasingly employed to achieve a balance between internal and external validity. Although these designs are often referred to and summarized in terms of logistical benefits, there is still uncertainty about (a) selecting from among various QEDs and (b) developing strategies to strengthen the internal and external validity of QEDs. We focus here on commonly used QEDs (prepost designs with nonequivalent control groups, interrupted time series, and stepped-wedge designs) and discuss several variants that maximize internal and external validity at the design, execution and implementation, and analysis stages.
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Affiliation(s)
- Margaret A Handley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California 94110, USA;
- Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
| | - Courtney R Lyles
- Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
| | - Charles McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California 94110, USA;
| | - Adithya Cattamanchi
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, California 94110, USA
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How to conduct implementation trials and multicentre studies in the emergency department. CAN J EMERG MED 2018; 20:448-452. [PMID: 29378671 DOI: 10.1017/cem.2017.433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of Panel 2b was to present an overview of and recommendations for the conduct of implementation trials and multicentre studies in emergency medicine. METHODS Panel members engaged methodologists to discuss the design and conduct of implementation and multicentre studies. We also conducted semi-structured interviews with 37 Canadian adult and pediatric emergency medicine researchers to elicit barriers and facilitators to conducting these kinds of studies. RESULTS Responses were organized by themes, and, based on these responses, recommendations were developed and refined in an iterative fashion by panel members. CONCLUSIONS We offer eight recommendations to facilitate multicentre clinical and implementation studies, along with guidance for conducting implementation research in the emergency department. Recommendations for multicentre studies reflect the importance of local study investigators and champions, requirements for research infrastructure and staffing, and the cooperation and communication between the coordinating centre and participating sites.
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Scales DC, Cheskes S, Verbeek PR, Pinto R, Austin D, Brooks SC, Dainty KN, Goncharenko K, Mamdani M, Thorpe KE, Morrison LJ. Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial. Resuscitation 2017; 121:187-194. [PMID: 28988962 DOI: 10.1016/j.resuscitation.2017.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
RATIONALE Targeted temperature management (TTM) improves survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA), but is delivered inconsistently and often with delay. OBJECTIVE To determine if prehospital cooling by paramedics leads to higher rates of 'successful TTM', defined as achieving a target temperature of 32-34°C within 6h of hospital arrival. METHODS Pragmatic RCT comparing prehospital cooling (surface ice packs, cold saline infusion, wristband reminders) initiated 5min after return of spontaneous circulation (ROSC) versus usual resuscitation and transport. The primary outcome was rate of 'successful TTM'; secondary outcomes were rates of applying TTM in hospital, survival with good neurological outcome, pulmonary edema in emergency department, and re-arrest during transport. RESULTS 585 patients were randomized to receive prehospital cooling (n=279) or control (n=306). Prehospital cooling did not increase rates of 'successful TTM' (30% vs 25%; RR, 1.17; 95% confidence interval [CI] 0.91-1.52; p=0.22), but increased rates of applying TTM in hospital (68% vs 56%; RR, 1.21; 95%CI 1.07-1.37; p=0.003). Survival with good neurological outcome (29% vs 26%; RR, 1.13, 95%CI 0.87-1.47; p=0.37) was similar. Prehospital cooling was not associated with re-arrest during transport (7.5% vs 8.2%; RR, 0.94; 95%CI 0.54-1.63; p=0.83) but was associated with decreased incidence of pulmonary edema in emergency department (12% vs 18%; RR, 0.66; 95%CI 0.44-0.99; p=0.04). CONCLUSIONS Prehospital cooling initiated 5min after ROSC did not increase rates of achieving a target temperature of 32-34°C within 6h of hospital arrival but was safe and increased application of TTM in hospital.
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Affiliation(s)
- D C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
| | - S Cheskes
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - P R Verbeek
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - R Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - D Austin
- Department of Emergency Medicine, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - S C Brooks
- Department of Emergency Medicine, Faculty of Health Sciences Queen's University, Kingston, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K N Dainty
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K Goncharenko
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - M Mamdani
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - K E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - L J Morrison
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Effect of enhanced feedback to hospitals that are part of an emerging clinical information network on uptake of revised childhood pneumonia treatment policy: study protocol for a cluster randomized trial. Trials 2017; 18:416. [PMID: 28877729 PMCID: PMC5588612 DOI: 10.1186/s13063-017-2152-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/16/2017] [Indexed: 11/15/2022] Open
Abstract
Background The national pneumonia treatment guidelines in Kenya changed in February 2016 but such guideline changes are often characterized by prolonged delays in affecting practice. We designed an enhanced feedback intervention, delivered within an ongoing clinical network that provides a general form of feedback, aimed at improving and sustaining uptake of the revised pneumonia treatment policy. The objective was to determine whether an enhanced feedback intervention will improve correctness of classification and treatment of childhood pneumonia, compared to an existing approach to feedback, after nationwide treatment policy change and within an existing hospital network. Methods/design A pragmatic, cluster randomized trial conducted within a clinical network of 12 Kenyan county referral hospitals providing inpatient pediatric care to children (aged 2–59 months) with acute medical conditions between March and November 2016. The intervention comprised enhanced feedback (monthly written feedback incorporating goal setting, and action planning delivered by a senior clinical coordinator for selected pneumonia indicators) and this was compared to standard feedback (2-monthly written feedback on multiple quality of pediatric care indicators) both delivered within a clinical network promoting clinical leadership linked to mentorship and peer-to-peer support, and improved use of health information on service delivery. The 12 hospitals were randomized to receive either enhanced feedback (n = 6) or standard feedback (n = 6) delivered over a 9-month period following nationwide pneumonia treatment policy change. The primary outcome is the proportion of all admitted patients with pneumonia (fulfilling criteria for treatment with orally administered amoxicillin) who are correctly classified and treated in the first 24 h. The secondary outcome will be measured over the course of the admission as any change in treatment for pneumonia after the first 24 h. Discussion This trial protocol employs a pragmatic trial design during a period of nationwide change in treatment guidelines to address two high-priority areas within implementation research: promoting adoption of health policies and optimizing effectiveness of feedback. Trial registration ClinicalTrials.gov, ID: NCT02817971. Registered retrospectively on 27 June 2016 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2152-8) contains supplementary material, which is available to authorized users.
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Dainty KN, Seaton B, Laupacis A, Schull M, Vaillancourt S. A qualitative study of emergency physicians' perspectives on PROMS in the emergency department. BMJ Qual Saf 2017; 26:714-721. [PMID: 28183828 PMCID: PMC5574389 DOI: 10.1136/bmjqs-2016-006012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/05/2017] [Accepted: 01/14/2017] [Indexed: 12/05/2022]
Abstract
INTRODUCTION There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. To date, this has been challenging in the emergency department (ED) setting. To better understand the root of this challenge, we looked to ED physicians' perspectives on their role, relationships and responsibilities to inform future development and implementation of patient-reported outcome measures (PROMs). METHODS ED physicians from hospitals across Canada were invited to participate in interviews using a snowballing sampling technique. Semistructured interviews were conducted by phone with questions focused on the role and practice of ED physicians, their relationship with their patients and their thoughts on patient-reported feedback as a mechanism for quality improvement. Transcripts were analysed using a modified constant comparative method and interpretive descriptive framework. RESULTS Interviews were completed with 30 individual physicians. Respondents were diverse in location, training and years in practice. Physicians reported being interested in 'objective' postdischarge information including adverse events, readmissions, other physicians' notes, etc in a select group of complex patients, but saw 'patient-reported' feedback as less valuable due to perceived biases. They were unsure about the impact of such feedback mainly because of the episodic nature of their work. Concerns about timing, as well as about their legal and ethical responsibilities to follow-up if poor patient outcomes are reported, were raised. CONCLUSIONS Data collection and feedback are key elements of a learning health system. While patient-reported outcomes may have a role in feedback, ED physicians are conflicted about the actionability of such data and ethical implications, given the inherently episodic nature of their work. These findings have important implications for PROM design and implementation in this unique clinical setting.
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Affiliation(s)
- Katie N Dainty
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Bianca Seaton
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Andreas Laupacis
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Michael Schull
- Institute of Clinically Evaluative Science, Toronto, Ontario, Canada
| | - Samuel Vaillancourt
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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Scales DC, Golan E, Pinto R, Brooks SC, Chapman M, Dale CM, Jichici D, Rubenfeld GD, Morrison LJ. Improving Appropriate Neurologic Prognostication after Cardiac Arrest. A Stepped Wedge Cluster Randomized Controlled Trial. Am J Respir Crit Care Med 2017; 194:1083-1091. [PMID: 27115286 DOI: 10.1164/rccm.201602-0397oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Predictions about neurologic prognosis that are based on early clinical findings after out-of-hospital cardiac arrest (OHCA) are often inaccurate and may lead to premature decisions to withdraw life-sustaining treatments (LST) in patients who might otherwise survive with good neurologic outcomes. OBJECTIVES To improve adherence to recommendations for appropriate neurologic prognostication after OHCA and reduce deaths from premature decisions to withdraw LST. METHODS This was a pragmatic stepped wedge cluster randomized controlled trial evaluating a multifaceted quality intervention (education, pathways, local champions, audit-feedback). The primary outcome was appropriate neurologic prognostication, defined as (1a) no early withdrawal of LST (WLST) (within 72 h) based on estimates of poor neurologic prognosis and (1b) no WLST between 72 hours and 7 days in absence of clinical predictors of poor neurologic prognosis or (2) surviving beyond 7 days. Secondary outcomes were deaths from early WLST and survival with good neurologic outcome. MEASUREMENTS AND MAIN RESULTS Between June 1, 2011, and June 30, 2014, a total of 905 patients with OHCA were enrolled from ICUs of 18 Ontario hospitals. Rates of appropriate neurologic prognostication increased after the intervention (68% vs. 74% patients; odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01-3.19; P = 0.05). However, rates of survival to hospital discharge (46% vs. 50%; OR, 1.71; 95% CI, 0.97-3.01; P = 0.06) and survival with good neurologic outcome remained similar (38% vs. 43%; OR, 1.43; 95% CI, 0.84-2.86; P = 0.19). CONCLUSIONS A multicenter quality intervention improved rates of appropriate neurologic prognostication after OHCA but did not increase survival with good neurologic outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 01472458).
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Affiliation(s)
- Damon C Scales
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,5 Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Eyal Golan
- 2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,7 Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- 1 Department of Critical Care Medicine and.,2 Interdepartmental Division of Critical Care
| | - Steven C Brooks
- 8 Department of Emergency Medicine, Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Martin Chapman
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care
| | - Craig M Dale
- 6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,9 Lawrence S. Bloomberg Faculty of Nursing, and
| | - Draga Jichici
- 10 Department of Neurology and Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada; and
| | - Gordon D Rubenfeld
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation
| | - Laurie J Morrison
- 3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,12 Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,11 Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Brooks SC, Scales DC, Pinto R, Dainty KN, Racz EM, Gaudio M, Amaral ACKB, Gray SH, Friedrich JO, Chapman M, Dorian P, Fam N, Fowler RA, Hayes CW, Baker A, Crystal E, Madan M, Rubenfeld G, Smith OM, Morrison LJ. The Postcardiac Arrest Consult Team: Impact on Hospital Care Processes for Out-of-Hospital Cardiac Arrest Patients. Crit Care Med 2017; 44:2037-2044. [PMID: 27509389 DOI: 10.1097/ccm.0000000000001863] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest. DESIGN Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others. SETTING Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada. PATIENTS We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management. INTERVENTION The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication. MEASUREMENTS AND MAIN RESULTS We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02-0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31-2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17-21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11-8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19-2.94). CONCLUSIONS Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.
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Affiliation(s)
- Steven C Brooks
- 1Department of Emergency Medicine, Queen's University, Kingston, ON, Canada. 2Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario Canada. 3Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 4Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. 5Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON. 6Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada. 7Department of Emergency Medicine, St. Michael's Hospital, Toronto, ON, Canada. 8Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. 9Heart and Vascular Program, St. Michael's Hospital, Toronto, ON, Canada. 10Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada. 11Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada. 12Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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13
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14
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Worthington H, Pickett W, Morrison LJ, Scales DC, Zhan C, Lin S, Dorian P, Dainty KN, Ferguson ND, Brooks SC. The impact of hospital experience with out-of-hospital cardiac arrest patients on post cardiac arrest care. Resuscitation 2016; 110:169-175. [PMID: 27658654 DOI: 10.1016/j.resuscitation.2016.08.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Patient volume as a surrogate for institutional experience has been associated with quality of care indicators for a variety of illnesses. We evaluated the association between hospital experience with comatose out-of-hospital cardiac arrest (OHCA) patients and important care processes. METHODS This was a population-based, retrospective cohort study using data from 37 hospitals in Southern Ontario from 2007 to 2013. We included adults with atraumatic OHCA who were comatose on emergency department arrival and survived at least 6h. We excluded patients with a Do-Not-Resuscitate order or severe bleeding within 6h of hospital arrival. Multi-level logistic regression models estimated the association between average annual hospital volume of OHCA patients and outcomes. The primary outcome was successful targeted temperature management (TTM) and secondary outcomes included TTM initiation, premature withdrawal of life-sustaining therapy, and survival with good neurologic function. RESULTS Our analysis included 2723 patients. For every increase of 10 in the average annual volume of eligible patients, the adjusted odds increased by 30% for successful TTM (OR 1.29, 95% CI 1.03-1.62) and by 38% for initiating TTM (OR 1.38, 95% CI 1.11-1.72). No significant association between patient volume and other secondary outcomes was observed. CONCLUSIONS Patients arriving at hospitals with more experience treating comatose post cardiac arrest patients are more likely to have TTM initiated and to successfully reach target temperature. Our findings have implications for regional systems of care and knowledge translation efforts aiming to improve quality of care for this patient population.
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Affiliation(s)
- Heather Worthington
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Will Pickett
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Damon C Scales
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdivisional Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Chun Zhan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Steve Lin
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Paul Dorian
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Katie N Dainty
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Niall D Ferguson
- Interdivisional Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Division of Respirology, Toronto General Research Institute, University Health Network and Mount Sinai Hospital, Toronto, Canada; Departments of Medicine and Physiology, Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
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15
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Girling AJ, Hemming K. Statistical efficiency and optimal design for stepped cluster studies under linear mixed effects models. Stat Med 2016; 35:2149-66. [PMID: 26748662 PMCID: PMC4949721 DOI: 10.1002/sim.6850] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 10/01/2015] [Accepted: 11/27/2015] [Indexed: 12/03/2022]
Abstract
In stepped cluster designs the intervention is introduced into some (or all) clusters at different times and persists until the end of the study. Instances include traditional parallel cluster designs and the more recent stepped-wedge designs. We consider the precision offered by such designs under mixed-effects models with fixed time and random subject and cluster effects (including interactions with time), and explore the optimal choice of uptake times. The results apply both to cross-sectional studies where new subjects are observed at each time-point, and longitudinal studies with repeat observations on the same subjects. The efficiency of the design is expressed in terms of a 'cluster-mean correlation' which carries information about the dependency-structure of the data, and two design coefficients which reflect the pattern of uptake-times. In cross-sectional studies the cluster-mean correlation combines information about the cluster-size and the intra-cluster correlation coefficient. A formula is given for the 'design effect' in both cross-sectional and longitudinal studies. An algorithm for optimising the choice of uptake times is described and specific results obtained for the best balanced stepped designs. In large studies we show that the best design is a hybrid mixture of parallel and stepped-wedge components, with the proportion of stepped wedge clusters equal to the cluster-mean correlation. The impact of prior uncertainty in the cluster-mean correlation is considered by simulation. Some specific hybrid designs are proposed for consideration when the cluster-mean correlation cannot be reliably estimated, using a minimax principle to ensure acceptable performance across the whole range of unknown values. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.
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Affiliation(s)
- Alan J. Girling
- Institute of Applied Health ResearchUniversity of BirminghamB15 2TTU.K.
| | - Karla Hemming
- Institute of Applied Health ResearchUniversity of BirminghamB15 2TTU.K.
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16
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Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
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Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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17
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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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Kotini-Shah P, Camp-Rogers TR, Swor RA, Sawyer KN. An Assessment of Emergency Department Post-Cardiac Arrest Care Variation in Michigan. Ther Hypothermia Temp Manag 2015; 6:17-22. [PMID: 26654317 DOI: 10.1089/ther.2015.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Implementation of postarrest care by individual physicians and systems has been slow. Deadoption, or discontinuation of therapeutic hypothermia (TH) treatment targets, after recent prospective study results has not been well reported. This study assesses practices in the early stages of postarrest care across emergency departments (EDs) in Michigan. A 27-question Internet-based survey was distributed to EDs in Michigan in September 2013. To assess changes in practice after publication of Nielsen et al., we sent follow-up questions to all original respondents a year later. Observational data and descriptive statistics are reported. From the 142 EDs identified, we excluded critical access hospitals (N = 35), free standing EDs (N = 7), EDs that transfer critical patients to tertiary centers (N = 21), and exclusive children's hospitals (N = 3). Of the remaining 76 hospitals, we received 64 (84.2%) responses. We identified 15 respondents with a protocol to specifically initiate ED TH and transfer patients to a higher level of care. The 49 remaining were mostly teaching institutions (N = 34, 69%) and gave the ED physician the ability to initiate TH (N = 40, 82%). On follow-up 12 months later, we received 33/40 (83%) responses, of which only 5 indicated formal or informal change in TH practice or target temperature. There is substantial variation in the practice of ED postarrest care and initiation of TH across the state of Michigan, but few ED TH protocols were changed in a year's time. The consequences of postarrest treatment variability at the state and ED levels are likely under-recognized as an influence on outcome variation between regions.
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Affiliation(s)
- Pavitra Kotini-Shah
- 1 Department of Emergency Medicine, University of Illinois at Chicago , Chicago, Illinois
| | - Teresa R Camp-Rogers
- 2 Department of Emergency Medicine, University of Texas Medical School at Houston , Houston, Texas
| | - Robert A Swor
- 3 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
| | - Kelly N Sawyer
- 3 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
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Beard E, Lewis JJ, Copas A, Davey C, Osrin D, Baio G, Thompson JA, Fielding KL, Omar RZ, Ononge S, Hargreaves J, Prost A. Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014. Trials 2015; 16:353. [PMID: 26278881 PMCID: PMC4538902 DOI: 10.1186/s13063-015-0839-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design's perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design. METHODS We searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy. RESULTS Our review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being 'instruction on how to perform a behaviour' (n = 32) and 'persuasive source' (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size. CONCLUSIONS The popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.
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Affiliation(s)
- Emma Beard
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
| | - Calum Davey
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Gianluca Baio
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Jennifer A Thompson
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Katherine L Fielding
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - James Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Prost A, Binik A, Abubakar I, Roy A, De Allegri M, Mouchoux C, Dreischulte T, Ayles H, Lewis JJ, Osrin D. Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies. Trials 2015; 16:351. [PMID: 26278521 PMCID: PMC4538739 DOI: 10.1186/s13063-015-0837-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Three arguments are usually invoked in favour of stepped wedge cluster randomised controlled trials: the logistic convenience of implementing an intervention in phases, the ethical benefit of providing the intervention to all clusters, and the potential to enhance the social acceptability of cluster randomised controlled trials. Are these alleged benefits real? We explored the logistic, ethical, and political dimensions of stepped wedge trials using case studies of six recent evaluations. Methods We identified completed or ongoing stepped wedge evaluations using two systematic reviews. We then purposively selected six with a focus on public health in high, middle, and low-income settings. We interviewed their authors about the logistic, ethical, and social issues faced by their teams. Two authors reviewed interview transcripts, identified emerging issues through qualitative thematic analysis, reflected upon them in the context of the literature, and invited all participants to co-author the manuscript. Results Our analysis raises three main points. First, the phased implementation of interventions can alleviate problems linked to simultaneous roll-out, but also brings new challenges. Issues to consider include the feasibility of organising intervention activities according to a randomised sequence, estimating time lags in implementation and effects, and accommodating policy changes during the trial period. Second, stepped wedge trials, like parallel cluster trials, require equipoise: without it, randomising participants to a control condition, even for a short time, remains problematic. In stepped wedge trials, equipoise is likely to lie in the degree of effect, effectiveness in a specific operational milieu, and the balance of benefit and harm, including the social value of better evaluation. Third, the strongest arguments for a stepped wedge design are logistic and political rather than ethical. The design is advantageous when simultaneous roll-out is impractical and when it increases the acceptability of using counterfactuals. Conclusions The logistic convenience of phased implementation is context-dependent, and may be vitiated by the additional requirements of phasing. The potential for stepped wedge trials to enhance the social acceptability of cluster randomised trials is real, but their ethical legitimacy still rests on demonstrating equipoise and its configuration for each research question and setting.
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Affiliation(s)
- Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | | | | | - Anjana Roy
- Public Health England (PHE), Colindale, UK.
| | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany.
| | | | | | - Helen Ayles
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Improving Use of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest. Crit Care Med 2015; 43:954-64. [DOI: 10.1097/ccm.0000000000000864] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fatemi Y, Jacobson RM. The stepped wedge cluster randomized trial and its potential for child health services research: a narrative review. Acad Pediatr 2015; 15:128-33. [PMID: 25613913 DOI: 10.1016/j.acap.2014.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 10/13/2014] [Accepted: 10/26/2014] [Indexed: 11/25/2022]
Affiliation(s)
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
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Targeted temperature management processes and outcomes after out-of-hospital cardiac arrest: an observational cohort study*. Crit Care Med 2015; 42:2565-74. [PMID: 25188550 DOI: 10.1097/ccm.0000000000000551] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Targeted temperature management has been shown to improve survival with good neurological outcome in patients after out-of-hospital cardiac arrest. The optimal approach to inducing and maintaining targeted temperature management, however, remains uncertain. The objective of this study was to evaluate these processes of care with survival and neurological function in patients after out-of-hospital cardiac arrest. DESIGN An observational cohort study evaluating the association of targeted temperature management processes with survival and neurological function using bivariate and generalized estimating equation analyses. SETTING Thirty-two tertiary and community hospitals in eight urban and rural regions of southern Ontario, Canada. PATIENTS Consecutive adult (≥ 18 yr) patients admitted between November 1, 2007, and January 31, 2012, and who were treated with targeted temperature management following nontraumatic out-of-hospital cardiac arrest. INTERVENTIONS Evaluate the association of targeted temperature management processes with survival and neurologic function using bivariate and generalized estimating equation analyses. MEASUREMENTS AND MAIN RESULTS There were 5,770 consecutive out-of-hospital cardiac arrest patients, of whom 747 (12.9%) were eligible and received targeted temperature management. Among patients with available outcome data, 365 of 738 (49.5%) survived to hospital discharge and 241 of 675 (35.7%) had good neurological outcomes. After adjusting for the Utstein variables, a higher temperature prior to initiation of targeted temperature management was associated with improved neurological outcomes (odds ratio, 1.27 per °C; 95% CI, 1.08-1.50; p = 0.004) and survival (odds ratio, 1.26 per °C; 95% CI, 1.09-1.46; p = 0.002). A slower rate of cooling was associated with improved neurological outcomes (odds ratio, 0.74 per °C/hr; 95% CI, 0.57-0.97; p = 0.03) and survival (odds ratio, 0.73 per °C/hr; 95% CI, 0.54-1.00; p = 0.049). CONCLUSIONS A higher baseline temperature prior to initiation of targeted temperature management and a slower rate of cooling were associated with improved survival and neurological outcomes. This may reflect a complex relationship between the approach to targeted temperature management and the extent of underlying brain injury causing impaired thermoregulation in out-of-hospital cardiac arrest patients.
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Drennan IR, Lin S, Sidalak DE, Morrison LJ. Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study. Resuscitation 2014; 85:1488-93. [DOI: 10.1016/j.resuscitation.2014.07.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/21/2014] [Accepted: 07/15/2014] [Indexed: 11/25/2022]
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Drennan IR, Lin S, Thorpe KE, Morrison LJ. The effect of time to defibrillation and targeted temperature management on functional survival after out-of-hospital cardiac arrest. Resuscitation 2014; 85:1623-8. [PMID: 25107539 DOI: 10.1016/j.resuscitation.2014.07.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/24/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cardiac arrest physiology has been proposed to occur in three distinct phases: electrical, circulatory and metabolic. There is limited research evaluating the relationship of the 3-phase model of cardiac arrest to functional survival at hospital discharge. Furthermore, the effect of post-cardiac arrest targeted temperature management (TTM) on functional survival during each phase is unknown. OBJECTIVE To determine the effect of TTM on the relationship between the time of initial defibrillation during each phase of cardiac arrest and functional survival at hospital discharge. METHODS This was a retrospective observational study of consecutive adult (≥18 years) out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythms. Included patients obtained a return of spontaneous circulation (ROSC) and were eligible for TTM. Multivariable logistic regression was used to determine predictors of functional survival at hospital discharge. RESULTS There were 20,165 OHCA treated by EMS and 871 patients were eligible for TTM. Of these patients, 622 (71.4%) survived to hospital discharge and 487 (55.9%) had good functional survival. Good functional survival was associated with younger age (OR 0.94; 95% CI 0.93-0.95), shorter times from collapse to initial defibrillation (OR 0.73; 95% CI 0.65-0.82), and use of post-cardiac arrest TTM (OR 1.49; 95% CI 1.07-2.30). Functional survival decreased during each phase of the model (65.3% vs. 61.7% vs. 50.2%, P<0.001). CONCLUSION Functional survival at hospital discharge was associated with shorter times to initial defibrillation and was decreased during each successive phase of the 3-phase model. Post-cardiac arrest TTM was associated with improved functional survival.
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Affiliation(s)
- Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Department of Medicine, University of Toronto, Toronto, ON, Canada; School of Health and Wellness, Georgian College, Barrie, ON, Canada.
| | - Steve Lin
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Applied Health Research Centre, St. Michael's Hospital, Toronto, ON, Canada.
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Prognostic evaluation in patients after CPR of cardiac cause by therapeutic hypothermia in coronary care unit of a Hospital University Cruces. Resuscitation 2014. [DOI: 10.1016/j.resuscitation.2014.03.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Scales DC. Partnering with health care payers to advance the science of quality improvement: lessons from the field. Am J Respir Crit Care Med 2011; 184:987-8. [PMID: 22045741 DOI: 10.1164/rccm.201107-1238ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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