A pragmatic cluster randomised trial evaluating three implementation interventions

Implementation of guidelines in clinical practice; barriers and strategies

PURPOSE OF REVIEW

Published clinical practice guidelines frequently have difficulties for implementation of the recommendations and adherence in daily clinical practice. The present review summarizes the current knowledge on the barriers encountered when implementing clinical practice guideline and the strategies proposed to address these barriers.

RECENT FINDINGS

Studies on strategies for implementation of clinical guidelines are scarce. Evidence indicates that a multidisciplinary policy is necessary in order to address the barriers at various levels. Continuous education and motivation of the stakeholders, together with structural adaptations are key elements in the process.

SUMMARY

The barriers for implementation of guidelines involve different levels, including the healthcare system, organizational, societal and cultural specificities, and individual attitudes. All of these should be addressed with policy-driven strategies. Such strategies could include optimization of resources allocations, and establishing well coordinated multidisciplinary networks, finally, future studies should also evaluate the effectiveness of the potential strategies.

Determining pre-procedure fasting alert time using procedural and scheduling data

Before a medical procedure requiring anesthesia, patients are required to not eat or drink non-clear fluids for 6 h and not drink clear fluids for 2 h. Fasting durations in standard practice far exceed these minimum thresholds due to uncertainties in procedure start time. The aim of this retrospective, observational study was to compare fasting durations arising from standard practice with different approaches for calculating the timepoint at which patients are instructed to stop eating and drinking. Scheduling data for procedures performed in the cardiac catheterization laboratory of an academic hospital in Canada (January 2020 to April 2022) were used. Four approaches utilizing machine learning (ML) and simulation were used to predict procedure start times and calculate when patients should be instructed to start fasting. Median fasting duration for standard practice was 10.08 h (IQR 3.5) for both food and clear fluids intake. The best performing alternative approach, using tree-based ML models to predict procedure start time, reduced median fasting from food/non-clear fluids to 7.7 h (IQR 2) and clear liquids fasting to 3.7 h (IQR 2.4). 97.3% met the minimum fasting duration requirements (95% CI 96.9% to 97.6%). Further studies are required to determine the effectiveness of operationalizing this approach as an automated fasting alert system.

The Implementation in Context (ICON) Framework: A meta-framework of context domains, attributes and features in healthcare

BACKGROUND

There is growing evidence that context mediates the effects of implementation interventions intended to increase healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what comprises context is elusive. The purpose of this study was to advance conceptual clarity on context by developing the Implementation in Context Framework, a meta-framework of the context domains, attributes and features that can facilitate or hinder healthcare professionals' use of research evidence and the effectiveness of implementation interventions in clinical practice.

METHODS

We conducted a meta-synthesis of data from three interrelated studies: (1) a concept analysis of published literature on context (n = 70 studies), (2) a secondary analysis of healthcare professional interviews (n = 145) examining context across 11 unique studies and (3) a descriptive qualitative study comprised of interviews with heath system stakeholders (n = 39) in four countries to elicit their tacit knowledge on the attributes and features of context. A rigorous protocol was followed for the meta-synthesis, resulting in development of the Implementation in Context Framework. Following this meta-synthesis, the framework was further refined through feedback from experts in context and implementation science.

RESULTS

In the Implementation in Context Framework, context is conceptualized in three levels: micro (individual), meso (organizational), and macro (external). The three levels are composed of six contextual domains: (1) actors (micro), (2) organizational climate and structures (meso), (3) organizational social behaviour (meso), (4) organizational response to change (meso), (5) organizational processes (meso) and (6) external influences (macro). These six domains contain 22 core attributes of context and 108 features that illustrate these attributes.

CONCLUSIONS

The Implementation in Context Framework is the only meta-framework of context available to guide implementation efforts of healthcare professionals. It provides a comprehensive and critically needed understanding of the context domains, attributes and features relevant to healthcare professionals' use of research evidence in clinical practice. The Implementation in Context Framework can inform implementation intervention design and delivery to better interpret the effects of implementation interventions, and pragmatically guide implementation efforts that enhance evidence uptake and sustainability by healthcare professionals.

Connecting the science and practice of implementation - applying the lens of context to inform study design in implementation research

The saying "horses for courses" refers to the idea that different people and things possess different skills or qualities that are appropriate in different situations. In this paper, we apply the analogy of "horses for courses" to stimulate a debate about how and why we need to get better at selecting appropriate implementation research methods that take account of the context in which implementation occurs. To ensure that implementation research achieves its intended purpose of enhancing the uptake of research-informed evidence in policy and practice, we start from a position that implementation research should be explicitly connected to implementation practice. Building on our collective experience as implementation researchers, implementation practitioners (users of implementation research), implementation facilitators and implementation educators and subsequent deliberations with an international, inter-disciplinary group involved in practising and studying implementation, we present a discussion paper with practical suggestions that aim to inform more practice-relevant implementation research.

Mapping research findings on change implementation in nursing practice: A scoping literature review

AIMS

The aim of this study was to map the diverse factors impacting change implementation in nursing practices and investigate different implementation strategies.

DESIGN

Scoping literature review following PRISMA-ScR extension.

METHODS

Data were collected from PubMed, Ebsco, Scopus and ScienceDirect databases from 1990 onwards. Only English peer-reviewed studies reporting an implementation of change in nursing practice were included. Of 9,954 studies, 425 abstracts were scanned and 98 full-text articles were screened. Finally, 28 studies were selected.

RESULTS

A multifaceted approach, with a tailored intervention, was the most effective implementation strategy. Most identified factors were considered systematic, for example resource availability, leadership and knowledge. However, others related to local social and material context were identified in fewer number of studies. These seem to be operational elements for implementation processes. Both types of factors are essential and must be considered for successful implementation.

CONCLUSION

We advocate the development of framework including systematic factors and which capture the local context flexibility.

Physicians' perceptions and preferences for implementing venous thromboembolism (VTE) clinical practice guidelines: a qualitative study using the Theoretical Domains Framework (TDF)

BACKGROUND

Venous thromboembolism is a primary cause of morbidity and mortality in hospitalised patients. Clinical practice guidelines were developed to prevent venous thromboembolism events. This study adopted the Theoretical Domains Framework to explore the beliefs and perceptions of physicians adoption of clinical practice guidelines for the uptake of venous thromboembolism prevention guidelines.

METHODS

Semi-structured interviews were conducted with a stratified purposive sample of internal medicine physicians in an acute hospital. The interview topic guide was developed using the Theoretical Domains Framework to identify the factors perceived to influence the practice. Two researchers coded the interview transcripts using thematic content analysis. Emerging relevant themes were mapped to TDF domains.

RESULTS

A total of sixteen medical physicians were interviewed over a six-month period. Nine theoretical domains derived from thirty-three belief statements were identified as relevant to the target behaviour; knowledge (education about the importance of VTE guidelines); beliefs about capabilities (with practice VTE tool easier to implement); beliefs about consequences (positive consequences in reducing the development of VTE, length of stay, financial burden and support physician decision) and (negative consequence risk of bleeding); reinforcement (recognition and continuous reminders); goals (patient safety goal); environmental context and resources (workload and availability of medications were barriers, VTE coordinator and electronic medical record were enablers); social influences (senior physicians and patient/family influence the VTE practice); behavioural regulation (monitoring and mandatory hospital policy); and nature of the behaviour.

CONCLUSIONS

Using the Theoretical Domains Framework, factors thought to influence the implementation of VTE clinical practice guidelines were identified which can be used to design theoretically based interventions by targeting specific psychological constructs and linking them to behaviour change techniques to change the clinical practice of physicians.

Process evaluations undertaken alongside randomised controlled trials in the hospital setting: A scoping review

Background

There is increasing recognition of the importance of undertaking process evaluations alongside implementation of health interventions by examining mechanisms of impact and contextual factors. However, a comprehensive synthesis of process evaluations undertaken alongside clinical trials in hospital settings is lacking. We undertook a scoping review to address this gap.

Methods

This review was guided by the methodological framework for scoping studies. Studies were identified using four databases; Ovid Medline, EBSCO CINAHL, EMBASE and Scopus. Two authors independently screened all titles and available abstracts, with a third author available to adjudicate. Studies were eligible for inclusion if they described a process evaluation undertaken alongside a randomised controlled trial in the hospital setting. Data were abstracted by one author and checked by two others and analysed both descriptively and using inductive content analysis.

Results

Data were extracted from 30 articles reporting on 15 trials, most of which were cluster randomised trials (c-RTs) (n = 12). The most common data collection methods used in process evaluations were interviews, questionnaires or surveys, and records or logs. Data analysis revealed three themes relative to how authors: use process data to interpret, understand and explain trial outcomes; evaluate responses to the intervention; and consider the implementation context.

Conclusions

Findings from this review demonstrate the complex nature of intervention implementation in the hospital setting. Overall, there is need for standardised reporting of process evaluations and more explicit descriptions of how authors use frameworks to guide their evaluation.

Accessibility, inclusivity, and implementation of COVID-19 clinical management guidelines early in the pandemic: a global survey

Background: With a rapidly changing evidence base, high-quality clinical management guidelines (CMGs) are key tools for aiding clinical decision making and increasing access to best available evidence-based care. A rapid review of COVID-19 CMGs found most lacked methodological rigour, overlooked at-risk populations, and varied in treatment recommendations. Furthermore, social science literature highlights the complexity of implementing guidelines in local contexts where they were not developed and the resulting potential to compound health inequities. This study aimed to evaluate access to, inclusivity of, and implementation of COVID-19 CMGs in different settings. Methods: A cross-sectional survey of clinicians worldwide was conducted from 15th June to 20th July 2020, to explore access to and implementation of COVID-19 CMGs, and treatment and supportive care recommendations provided. Data on accessibility, inclusivity, and implementation of CMGs were analysed by geographic location. Results: 76 clinicians from 27 countries responded: 82% from high-income countries, 17% from lower middle-income countries (LMICs). Most respondents reported access to COVID-19 CMGs and confidence in their implementation. However, many respondents, particularly from LMICs, reported barriers to implementation, including limited access to treatment and equipment. Only 20% of respondents reported having access to CMGs covering care for children, 25% for pregnant women, and 50% for older adults (>65 years). Identified themes were for CMGs to include recommendations for at-risk populations and settings, include supportive care guidance, and be updated as evidence emerges, and for clinicians to have training and access to recommended treatments to support implementation. Conclusion: Our findings highlight important gaps in COVID-19 CMG development and implementation challenges during a pandemic, particularly affecting at-risk populations and lower resourced settings. This study identifies an urgent need for an improved CMG development framework that is inclusive and adaptable to emerging evidence and considers contextual implementation support, to improve access to evidence-based care globally.

Educating health professionals to implement evidence-based falls screening in hospitals

OBJECTIVE

International evidence-based guidelines advise traditional Falls Risk Assessment Tools (FRATs) should not be routinely used to predict the risk of a patient falling in hospital. However, disinvestment from existing services can be challenging. This study applied evidence-based approaches to education design to implement best practice guidelines.

DESIGN

Mixed methods using questionnaires to evaluate health professionals' knowledge of evidence-based falls risk assessment and mitigation, followed by semi-structured interviews with individual health professionals.

SETTING

Five Australian hospitals.

PARTICIPANTS

There were two cohorts per hospital; Cohort 1 (C1) comprised 10 clinical leaders from nursing and allied health professions. Cohort 2 (C2) included clinicians involved in routine hospital falls screening and prevention.

METHODS

46 clinical leaders received a 3-h high quality education workshop on the latest evidence in hospital falls risk assessment and how to implement a new falls screening and management tool. They were also taught the practical skills to deliver a 1-h education session to C2 (n = 129).

RESULTS

The education workshop significantly changed C1's views about evidence-based guidelines for falls screening and prevention. C1 were significantly more likely than C2 to feel confident in assessing falls risk and judging and implementing the best mitigation strategies. After the workshop, C1 were prepared and motivated to educate others on falls prevention and were satisfied with the skills gained. Six months after the workshop, C1 reported feeling more prepared for preventing falls.

CONCLUSION

Health professionals benefitted from an interactive education workshop on how to use a new evidence-based hospital falls screening tool to help mitigate risk. An abridged version of the workshop did not result in long lasting effects. Education is an important element aiding disinvestment from non-evidence-based services, and implementation of clinical guidelines.

Lagniappes: "A Little Something Extra" or Unintended Positive Consequences of Implementation Facilitation

OBJECTIVE

Implementation facilitation is an effective strategy that increases uptake of behavioral health interventions. Facilitation is grounded in partnerships with leadership and clinical stakeholders. Researchers have documented some negative consequences of facilitation-time, financial, and opportunity costs. Clinical leaders often agree to facilitation with the promise of increased implementation of an intervention. This study examined whether unintended positive consequences of facilitation might offset known costs.

METHODS

This study was part of a stepped-wedge, hybrid type 2, pragmatic trial that used implementation facilitation to implement primary care mental health integration (PCMHI) via telehealth technology in six satellite Veterans Health Administration (VHA) clinics. Two facilitators provided facilitation for at least 6 months. This study included a focused analysis of an emerging phenomenon captured through weekly debriefing interviews with facilitators: unintended positive consequences of implementation facilitation, termed "lagniappes" here. A rapid content analysis was conducted to identify and categorize these consequences.

RESULTS

The authors documented unintended positive consequences of the facilitation across the six VHA sites and categorized them into three clinically relevant domains: supporting PCMHI outreach at other clinics not in the original catchment area (e.g., providing tools to other sites), strengthening patient access (e.g., resolving unnecessary patient travel), and improving or modifying work processes (e.g., clarifying suicide assessment protocols). The positive consequences benefited sites and strengthened ongoing partnerships.

CONCLUSIONS

Documenting unintended positive consequences of implementation facilitation may increase leadership engagement. Facilitators should consider leveraging unintended positive consequences as advantages for the site that may add efficiency to facility processes and workflows.

Early impact of the 2018 AHA/ACC/multisociety cholesterol guideline on lipid monitoring after statin initiation

BACKGROUND

The 2018 AHA/ACC/multisociety cholesterol guideline emphasizes the need for lipid monitoring more strongly than the previous 2013 guideline to ensure patients reach recommended percent low-density lipoprotein cholesterol reductions. Real-world compliance to monitoring recommendations is currently unknown.

OBJECTIVES

This study examined the proportion of patients with a lipid panel measured within 3 months of statin initiation.

METHODS

This retrospective cohort study evaluated University of Colorado Health primary care patients aged 18 to 89 years with a new statin prescription identified via the Epic Clarity database. Patients initiated on a statin during January 1, 2018 to June 30, 2018 and January 1, 2019 to June 30, 2019 were included in the pre-2018 guideline cohort and the post-2018 guideline cohort, respectively. Patients with active liver disease, pregnancy, or missing demographic data were excluded.

RESULTS

A total of 13,726 patients were included, 7476 in the preguideline cohort and 6250 in the postguideline cohort. A total of 13.9% of patients in the preguideline cohort had a lipid panel completed within 3 months of statin initiation compared with 16.2% in the postguideline cohort (adjusted P < .001). In the postguideline cohort, 56% (n = 857) of patients with lipid monitoring warranted a therapeutic intensification as recommended by the 2018 guideline; however, only 5% had their lipid-lowering regimen changed.

CONCLUSION

In a large integrated health system, lipid monitoring increased among patients newly started on statin therapy soon after release of the 2018 guideline but remains low. Clinical interventions are needed to improve lipid monitoring to optimize low-density lipoprotein cholesterol-lowering therapy and ensure that guideline-recommended goals are achieved.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Barriers and enablers to conducting cluster randomized control trials in hospitals: A theory-informed scoping review

BACKGROUND

Cluster randomized control trials (cRCTs) have unique challenges compared to single site trials with regards to conduct of the trial, and it is important to understand these barriers. The aim of this scoping review was to describe the current literature surrounding the implementation of the cRCTs in hospitals.

METHODS

The search strategy was designed to identify literature relevant to conduct of cRCTs, with hospitals as the unit of randomization. Data was extracted and was mapped using the Consolidated Framework for Implementation Research (CFIR) as a codebook, which contains 39 constructs organized into five domains.

RESULTS

Twenty-two articles met inclusion criteria and were included. 18 of 39 constructs of the CFIR were identified in coding, spanning four of the five domains. Barriers to the conduct of the trial were rarely reported as the main outcome of the study, and few details were included in the identified literature.

CONCLUSIONS

The review can provide guidance to future researchers planning cRCTs in hospitals. It also identified a large gap in reporting of conduct of these trials, demonstrating the need for a research agenda that further explores the barriers and facilitators, with the aim of garnering knowledge for improved guidance in the implementation.

Quality improvement in mental health services

Quality improvement (QI) approaches are becoming increasingly important in the delivery of mental healthcare internationally. They were originally developed in the manufacturing industry, but the principle of having a systematic approach to improvement has spread to many other industries, not least to healthcare. Quality improvement approaches in healthcare were pioneered in the USA at organisations such as Virginia Mason and the Institute for Healthcare Improvement. In recent years, they have become firmly established in mental health services in the UK's National Health Service (NHS). There are a number of different approaches to quality improvement, but two leading models have taken root: 'lean thinking' (also known as 'lean methodology' or simply 'lean'), which arose out of Virginia Mason, and the 'Model for Improvement', which came out of the Institute of Healthcare Improvement. This article describes these two quality improvement approaches, critiques their philosophy and explores how they can apply in the provision of mental healthcare, particularly with reference to the use of data, evidence and metrics.

Challenges in Clinical Trial Implementation: Results from a Survey of the National Accreditation Program of Breast Centers (NAPBC)

BACKGROUND

Although the results of clinical trials often guide best practices, changing clinical practice based on clinical trial results can be challenging. The objective of this study was to examine provider-reported barriers to adopting best clinical practices according to clinical trial data.

METHODS

A cross-sectional survey was conducted of providers from the National Accreditation Program for Breast Centers about barriers that prevent the incorporation of trial findings. Descriptive analyses and multivariable analyses were performed to determine provider characteristics that were significantly associated with reported barriers.

RESULTS

Overall, 383 institutions participated (63.5% response rate), with a total of 1226 physicians responding to the survey (80% response rate). Providers identified national guidelines and meetings as the most compelling way to receive practice-changing information. They reported the following internal barriers to trial implementation: patient preference (45%), strongly held beliefs by partners/colleagues (37%), and insufficient time to discuss new practices (30%). External barriers preventing trial implementation included a lack of agreement from multidisciplinary tumor boards (32%), fear of reimbursement loss (23%), and resistance from clinical staff (20%). Reported barriers differed by provider specialty, with plastic surgeons and radiation oncologists reporting that strongly held beliefs by partners/colleagues and disagreement from multidisciplinary tumor boards were the most significant factors preventing clinical trial implementation.

CONCLUSIONS

Physician beliefs and patient preferences are the most frequently reported barriers to clinical trial implementation. Tactics to better educate providers about how to explain new clinical trial data to their patients and colleagues are needed.

Perceptions of physicians in Saudi Arabia on the use of international clinical guidelines for managing primary insomnia

INTRODUCTION

While there are no national clinical guidelines for managing primary insomnia in Saudi Arabia, there are also no published studies of physicians' perceptions of and attitudes towards using international guidelines. The objective of this study was to explore the knowledge, perceptions, and attitudes of physicians practising in Saudi Arabia about using international guidelines for managing insomnia.

METHODS

A qualitative study using in-depth, face-to-face, and semi-structured interviews with 15 physicians held in July 2017 at a tertiary care hospital in Jazan, the distal south-western province in Saudi Arabia. Interviews were audio-recorded, transcribed verbatim, coded using the qualitative software NVivo11 and analysed thematically. Data saturation was assumed as no new understandings of the broad thematic issues were produced by the last three interviews.

RESULTS

Themes identified were: Knowledge, Resistance, Barriers and Facilitators. Participants acknowledged their lack of awareness of available guidelines and their lack of training and education about Cognitive Behavioural Therapy for Insomnia (CBT-I). They highlighted a lack of education for patients about insomnia and its treatment. Beliefs about dependence on hypnotics and the inappropriateness of international guidelines for Saudi Arabia inclined many to resist using them. Inability to document diagnosis and consultations due to limited time and lack of suitable electronic systems, lack of suitably trained practitioners for referral for CBT-I, and lack of accountability for practice were identified as key barriers to following international guidelines. Development of national guidelines was the most important facilitator suggested by participants.

CONCLUSIONS

The health authorities in the government of the Kingdom of Saudi Arabia (KSA) should improve general public awareness about sleep disorders and provide focused training for specialists and technologists. Above all, KSA needs its own nationwide guidelines for treating sleep-disorders based on evidence-based clinical trials, consistent with its history, culture, socioeconomic conditions and traditions.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework

BACKGROUND

Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.

METHODS

A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.

RESULTS

Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.

CONCLUSIONS

This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

Shedding light on conditions for the successful passive dissemination of recommendations in primary care: a mixed methods study

BACKGROUND

Passive dissemination of information in healthcare refers to the publication or mailing of newly established guidelines or recommendations. It is one of the least costly knowledge translation activities. This approach is generally considered to be ineffective or to result in only small changes in practice. Recent research, however, suggests that passive dissemination could, under certain conditions, result in modifications of practice, similar to more active dissemination approaches. The objective of our study was to uncover the conditions associated with the change in primary care practice, namely Family Medicine Groups (FMGs) in Quebec (Canada), following the passive dissemination of recommendations for the diagnosis and management of Alzheimer's disease and related dementia (AD).

METHODS

We used a three-step, innovative, convergent mixed methods design based on a multiple case study in eight FMGs. Two studies were conducted in parallel: (1) a before and after retrospective chart review and a cluster analysis of FMGs performed on two clinical performance indicators-the rate of AD diagnosis and the quality of follow-up care; (2) a qualitative descriptive study using interviews and focus groups with FMG clinicians and healthcare managers. The results were integrated using joint displays.

RESULTS

After the passive dissemination of the recommendations, some FMGs started to implement the recommendations while other FMGs did not change their practice with respect to the AD diagnosis rate and quality of follow-up care. Three interrelated conditions were identified for the successful passive dissemination of clinical recommendations: (1) FMG clinicians with a moderate to high baseline expertise and confidence, which was linked to their existing collaboration with hospital-based specialists in dementia and their motivation; (2) the presence of a self-identified champion (individual champion or collective championship) in the FMGs taking the lead, motivating the clinical staff or organizing training; (3) the availability of sufficient clinical staff enabled these two conditions to have an impact on the implementation of recommendations through passive dissemination.

CONCLUSIONS

Passive dissemination of clinical recommendations, a low-cost knowledge translation approach, may lead to practice change under some specific conditions. More active dissemination efforts may only be needed in sites where these conditions are absent.

Implementation Science in Perioperative Care

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

Effectiveness of knowledge translation and knowledge appropriation of clinical practice guidelines for patients and communities, a systematic review

Introduction: Knowledge translation and knowledge appropriation social interventions apply knowledge to improve health services and outcomes. These interventions can be implemented routinely to improve patient adherence to clinical practice guidelines. Objective: To assess the effectiveness of knowledge translation interventions to improve patient and community adherence to clinical practice guidelines. Materials and methods: We performed a systematic review of these interventions compared with classical interventions for patients and/or communities. We searched the following electronic databases up to April 2017: Medline (Ovid), Embase, Scopus, Central (Ovid), Web of Science, LILACS, Academic Search, and Scielo. Two independent raters qualified the relevance, risk of bias, and quality of included studies. Results: Eight studies were included. Patient adherence to recommendations was observed in two studies. There was high heterogeneity due to the variability of the population, types of guidelines, and types of measurement tools. The risk of bias was high: a 60% risk of performance bias, 50% risk of attrition bias, 25% risk of selection and reporting bias, and 15% risk of detection bias. The quality of evidence was moderate for the outcomes of adherence and mortality. The interventions that used a combination of strategies, such as with the group of health professionals, could improve some clinical outcomes in the patients (Average deviation: -3.00; 95% IC: -6.08-0.08). Conclusions: Knowledge translation interventions might have a slight positive effect on patient adherence and some short-term clinical outcomes, particularly within mixed interventions (patients and health professionals). However, future studies with less heterogeneity are necessary to confirm these results.

Inside help: An integrative review of champions in healthcare-related implementation

Background/aims:

The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and bring greater clarity to this important construct.

Methods:

This integrative review was limited to research articles in peer-reviewed, English-language journals published from 1980 to 2016. Searches were conducted on the online MEDLINE database via OVID and PubMed using the keyword “champion.” Several additional terms often describe champions and were also included as keywords: implementation leader, opinion leader, facilitator, and change agent. Bibliographies of full-text articles that met inclusion criteria were reviewed for additional references not yet identified via the main strategy of conducting keyword searches in MEDLINE. A five-member team abstracted all full-text articles meeting inclusion criteria.

Results:

The final dataset for the integrative review consisted of 199 unique articles. Use of the term champion varied widely across the articles with respect to topic, specific job positions, or broader organizational roles. The most common method for operationalizing champion for purposes of analysis was the use of a dichotomous variable designating champion presence or absence. Four studies randomly allocated of the presence or absence of champions.

Conclusions:

The number of published champion-related articles has markedly increased: more articles were published during the last two years of this review (i.e. 2015–2016) than during its first 30 years (i.e. 1980–2009).

The number of champion-related articles has continued to increase sharply since the year 2000. Individual studies consistently found that champions were important positive influences on implementation effectiveness. Although few in number, the randomized trials of champions that have been conducted demonstrate the feasibility of using experimental design to study the effects of champions in healthcare.

Frequency and Variables Associated with Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders-Ulcerative Colitis (ADORE-UC) Study

INTRODUCTION

Current clinical practice guidelines suggest that patients with ulcerative colitis (UC) hospitalized because of a disease flare should be offered a normal diet, unless such a diet is not tolerated. Studies of hospitalized patients have demonstrated iatrogenic malnutrition from unjustified or inappropriate nil per os (NPO) or clear liquid diet (CLD) orders. In this study, we aim to characterize the burden of this problem in hospitalized patients with UC.

METHODS

We conducted a retrospective cohort study of all patients with UC admitted to the gastroenterology service or the general internal medicine service at a tertiary, academic hospital between January 2009 and December 2014, with a length of stay between 2 and 30 days. The frequency and duration of bowel rest and CLD orders was recorded, and the number of meals missed because of these orders was assessed. NPO or CLD diet orders were considered justified if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy, or if alternative enteral nutrition was provided. Clinical and demographic factors associated with unjustified underfeeding were identified.

RESULTS

A total of 187 admissions among 158 patients with UC were identified during the study period and included in the final analysis. Most admissions were to the gastroenterology service (148/187, 79.1%). The mean age at admission was 35.0 years (SD = 15), and 83/158 (52.5%) were female. The median length of stay was 8 days (interquartile range = 4-12). Registered dietician consultation was obtained in only 32 admissions (17.1%), and admission weight was recorded in only 68 (36.4%) admissions. A total of 252 NPO or CLD dietary orders were encountered in 142 admissions (75.9%). Of those, 112 orders were unjustified (44%). On average, patients with unjustified NPO or CLD orders spent 3 days on an NPO or CLD diet, which corresponded to a mean of 10 missed meals. Characteristics associated with unnecessary fasting included female gender, less frequent endoscopic disease staging, less frequent escalation of therapy to prednisone and/or biologics, and admission to a non-gastroenterology service.

CONCLUSIONS

There is a high burden of unjustified underfeeding among hospitalized patients with UC, particularly in patients admitted without evidence of objective disease flare. This may lead to nutritional compromise in an at-risk population, and further studies are needed to assess the nutritional impact of unjustified bowel rest on patients with UC. Our findings also suggest that targeted quality improvement interventions are needed to decrease the frequency of inappropriate bowel rest among hospitalized patients with UC.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

Implementation of effective practices in health facilities: a systematic review of cluster randomised trials

Background

The capacity for health systems to support the translation of research in to clinical practice may be limited. The cluster randomised controlled trial (cluster RCT) design is often employed in evaluating the effectiveness of implementation of evidence-based practices. We aimed to systematically review available evidence to identify and evaluate the components in the implementation process at the facility level using cluster RCT designs.

Methods

All cluster RCTs where the healthcare facility was the unit of randomisation, published or written from 1990 to 2014, were assessed. Included studies were analysed for the components of implementation interventions employed in each. Through iterative mapping and analysis, we synthesised a master list of components used and summarised the effects of different combinations of interventions on practices.

Results

Forty-six studies met the inclusion criteria and covered the specialty groups of obstetrics and gynaecology (n=9), paediatrics and neonatology (n=4), intensive care (n=4), internal medicine (n=20), and anaesthetics and surgery (n=3). Six studies included interventions that were delivered across specialties. Nine components of multifaceted implementation interventions were identified: leadership, barrier identification, tailoring to the context, patient involvement, communication, education, supportive supervision, provision of resources, and audit and feedback. The four main components that were most commonly used were education (n=42, 91%), audit and feedback (n=26, 57%), provision of resources (n=23, 50%) and leadership (n=21, 46%).

Conclusions

Future implementation research should focus on better reporting of multifaceted approaches, incorporating sets of components that facilitate the translation of research into practice, and should employ rigorous monitoring and evaluation.

Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document

OBJECTIVES

Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies.

METHODS

An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts.

RESULTS

The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice.

CONCLUSIONS

Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice.

Selecting and training opinion leaders and best practice collaborators: experience from the Canadian Chiropractic Guideline Initiative

OBJECTIVES

To describe the process for selecting and training chiropractic opinion leaders (OLs) and best practice collaborators (BPCs) to increase the uptake of best practice.

METHODS

In Phase 1, OLs were identified using a cross-sectional survey among Canadian chiropractic stakeholders. A 10-member committee ranked nominees. Top-ranked nominees were invited to a training workshop. In Phase 2, a national e-survey was administered to 7200 Canadian chiropractors to identify additional OLs and BPCs. Recommended names were screened by OLs and final selection made by consensus. Webinars were utilized to train BPCs to engage peers in best practices, and facilitate guideline dissemination.

RESULTS

In Phase 1, 21 OLs were selected from 80 nominees. Sixteen attended a training workshop. In Phase 2, 486 chiropractors recommended 1126 potential BPCs, of which 133 were invited to participate and 112 accepted.

CONCLUSIONS

OLs and BPCs were identified across Canada to enhance the uptake of research among chiropractors.

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines

BACKGROUND

The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.

OBJECTIVES

To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines.

MAIN RESULTS

We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.

AUTHORS' CONCLUSIONS

Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.

Barriers and Strategies in Guideline Implementation-A Scoping Review

Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.

How Well Is Quality Improvement Described in the Perioperative Care Literature? A Systematic Review

BACKGROUND

Quality improvement (QI) approaches are widely used across health care, but how well they are reported in the academic literature is not clear. A systematic review was conducted to assess the completeness of reporting of QI interventions and techniques in the field of perioperative care.

METHODS

Searches were conducted using Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Effective Practice and Organization of Care database, and PubMed. Two independent reviewers used the Template for Intervention Description and Replication (TIDieR) check list, which identifies 12 features of interventions that studies should describe (for example, How: the interventions were delivered [e. g., face to face, internet]), When and how much: duration, dose, intensity), to assign scores for each included article. Articles were also scored against a small number of additional criteria relevant to QI.

RESULTS

The search identified 16,103 abstracts from databases and 19 from other sources. Following review, full-text was obtained for 223 articles, 100 of which met the criteria for inclusion. Completeness of reporting of QI in the perioperative care literature was variable. Only one article was judged fully complete against the 11 TIDieR items used. The mean TIDieR score across the 100 included articles was 6.31 (of a maximum 11). More than a third (35%) of the articles scored 5 or lower. Particularly problematic was reporting of fidelity (absent in 74% of articles) and whether any modifications were made to the intervention (absent in 73% of articles).

CONCLUSIONS

The standard of reporting of quality interventions and QI techniques in surgery is often suboptimal, making it difficult to determine whether an intervention can be replicated and used to deliver a positive effect in another setting. This suggests a need to explore how reporting practices could be improved.

PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice

Background

The Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement.

Discussion

Building on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework.

Summary

This paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0398-2) contains supplementary material, which is available to authorized users.

Application of simplified Complexity Theory concepts for healthcare social systems to explain the implementation of evidence into practice

AIM

To examine the application of core concepts from Complexity Theory to explain the findings from a process evaluation undertaken in a trial evaluating implementation strategies for recommendations about reducing surgical fasting times.

BACKGROUND

The proliferation of evidence-based guidance requires a greater focus on its implementation. Theory is required to explain the complex processes across the multiple healthcare organizational levels. This social healthcare context involves the interaction between professionals, patients and the organizational systems in care delivery. Complexity Theory may provide an explanatory framework to explain the complexities inherent in implementation in social healthcare contexts.

DESIGN

A secondary thematic analysis of qualitative process evaluation data informed by Complexity Theory.

METHOD

Seminal texts applying Complexity Theory to the social context were annotated, key concepts extracted and core Complexity Theory concepts identified. These core concepts were applied as a theoretical lens to provide an explanation of themes from a process evaluation of a trial evaluating the implementation of strategies to reduce surgical fasting times. Sampled substantive texts provided a representative spread of theoretical development and application of Complexity Theory from late 1990's-2013 in social science, healthcare, management and philosophy.

FINDINGS

Five Complexity Theory core concepts extracted were 'self-organization', 'interaction', 'emergence', 'system history' and 'temporality'. Application of these concepts suggests routine surgical fasting practice is habituated in the social healthcare system and therefore it cannot easily be reversed. A reduction to fasting times requires an incentivised new approach to emerge in the surgical system's priority of completing the operating list.

CONCLUSION

The application of Complexity Theory provides a useful explanation for resistance to change fasting practice. Its utility in implementation research warrants further attention and evaluation.

Frequency and Appropriateness of Fasting Orders in the Hospital

OBJECTIVE

To evaluate the frequency and appropriateness of nil per os (nothing by mouth) (NPO) orders and determine the number of meals missed because of these orders among hospitalized patients.

PATIENTS AND METHODS

We retrospectively analyzed inpatient NPO orders at an academic institution in the United States. The frequency and duration of NPO orders and the number of meals missed because of these orders were assessed for adult patients admitted to the hospital medicine services from January 1, 2013, through December 31, 2013, with a hospital stay of 2 or more and 30 or fewer days. Two blinded reviewers assessed if the order could be avoided or the period shortened for a random sample of NPO orders of 120 or more minutes' duration that were written for patients on the general medicine ward.

RESULTS

A total of 3641 NPO orders were identified. At least one NPO order was placed in 46.6% of the admissions (2211 of 4743). The median duration of NPO orders was 12.8 hours (interquartile range, 9.2-17.3 hours), resulting in 2 (interquartile range, 1-4) missed meals. Of 1130 NPO orders reviewed, 263 (23.3%; 95% CI, 20.9%-25.8%) were deemed avoidable (κ statistic, 0.68), and 482 (42.7%) were unavoidable but led to more missed meals than needed. Taken together, patients could have had 44.8% of the meals (1085 of 2424; 95% CI, 42.8%-46.7%) missed due to NPO orders.

CONCLUSION

Approximately half of the patients admitted to the hospital medicine services experienced a period of fasting. One in 4 NPO orders and nearly half of missed meals could have been avoided. Further study is warranted to assess the generalizability of our findings.

The implausibility of 'usual care' in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background

The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods

Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results

Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions

We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

Improving occupational physicians' adherence to a practice guideline: feasibility and impact of a tailored implementation strategy

BACKGROUND

Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs' barriers were evaluated.

METHODS

OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs' experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training.

RESULTS

The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01).

CONCLUSIONS

The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs' knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care

Background

In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities.

Methods

This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis.

Results

In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills.

Conclusion

The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice.

Implementing an Injury Prevention Briefing to aid delivery of key fire safety messages in UK children's centres: qualitative study nested within a multi-centre randomised controlled trial

Background

To improve the translation of public health evidence into practice, there is a need to increase practitioner involvement in initiative development, to place greater emphasis on contextual knowledge, and to address intervention processes and outcomes. Evidence that demonstrates the need to reduce childhood fire-related injuries is compelling but its translation into practice is inconsistent and limited. With this knowledge the Keeping Children Safe programme developed an "Injury Prevention Briefing (IPB)" using a 7 step process to combine scientific evidence with practitioner contextual knowledge. The IPB was designed specifically for children’s centres (CCs) to support delivery of key fire safety messages to parents. This paper reports the findings of a nested qualitative study within a clustered randomised controlled trial of the IPB, in which staff described their experiences of IPB implementation to aid understanding of why or how the intervention worked.

Methods

Interviews were conducted with key staff at 24 CCs participating in the two intervention arms: 1) IPB supplemented by initial training and regular facilitation; 2) IPB sent by post with no facilitation. Framework Analysis was applied to these interview data to explore intervention adherence including; exposure or dose; quality of delivery; participant responsiveness; programme differentiation; and staff experience of IPB implementation. This included barriers, facilitators and suggested improvements.

Results

83% of CCs regarded the IPB as a simple, accessible tool which raised awareness, and stimulated discussion and behaviour change. 15 CCs suggested minor modifications to format and content. Four levels of implementation were identified according to content, frequency, duration and coverage. Most CCs (75%) achieved ‘extended’ or ‘essential’ IPB implementation. Three universal factors affected all CCs: organisational change and resourcing; working with hard to engage groups; additional demands of participating in a research study. Six specific factors were associated with the implementation level achieved: staff engagement and training; staff continuity; adaptability and flexibility; other agency support; conflicting priorities; facilitation. CCs achieving high implementation levels increased from 58% (no facilitation) to 92% with facilitation.

Conclusion

Incorporating service provider perspectives and scientific evidence into health education initiatives enhances potential for successful implementation, particularly when supplemented by ongoing training and facilitation.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1256) contains supplementary material, which is available to authorized users.

How pragmatic is it? Lessons learned using PRECIS and RE-AIM for determining pragmatic characteristics of research

Background

The need for high-quality evidence that is applicable in real-world, routine settings continues to increase. Pragmatic trials are designed to evaluate the effectiveness of interventions in real-world settings, whereas explanatory trials aim to test whether an intervention works under optimal situations. There is a continuum between explanatory and pragmatic trials. Most trials have aspects of both, making it challenging to label and categorize a trial and to evaluate its potential for translation into practice.

Methods

We summarize our experience applying the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) combined with external validity items based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to three studies to provide a more robust and comprehensive assessment of trial characteristics related to translation of research. We summarize lessons learned using domains from the combined frameworks for use in study planning, evaluating specific studies, and reviewing the literature and make recommendations for future use.

Results

A variety of coders can be trained to use the PRECIS and RE-AIM domains. These domains can also be used for diverse purposes, content areas, and study types, but are not without challenges. Both PRECIS and RE-AIM domains required modification in two of the three studies to evaluate and rate domains specific to study type. Lessons learned involved: dedicating enough time for training activities related to the domains; use of reviewers with a range of familiarity with specific study protocols; how to best adapt ratings that reflect complex study designs; and differences of opinion regarding the value of creating a composite score for these criteria.

Conclusions

Combining both frameworks can specifically help identify where and how a study is and is not pragmatic. Using both PRECIS and RE-AIM allows for standard reporting of key study characteristics related to pragmatism and translation. Such measures should be used more consistently to help plan more pragmatic studies, evaluate progress, increase transparency of reporting, and integrate literature to facilitate translation of research into practice and policy.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0096-x) contains supplementary material, which is available to authorized users.

Facilitators and barriers to applying a national quality registry for quality improvement in stroke care

BACKGROUND

National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden.

METHODS

A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis.

RESULTS

An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data.

CONCLUSION

While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework

Background

The case has been made for more and better theory-informed process evaluations within trials in an effort to facilitate insightful understandings of how interventions work. In this paper, we provide an explanation of implementation processes from one of the first national implementation research randomized controlled trials with embedded process evaluation conducted within acute care, and a proposed extension to the Promoting Action on Research Implementation in Health Services (PARIHS) framework.

Methods

The PARIHS framework was prospectively applied to guide decisions about intervention design, data collection, and analysis processes in a trial focussed on reducing peri-operative fasting times. In order to capture a holistic picture of implementation processes, the same data were collected across 19 participating hospitals irrespective of allocation to intervention. This paper reports on findings from data collected from a purposive sample of 151 staff and patients pre- and post-intervention. Data were analysed using content analysis within, and then across data sets.

Results

A robust and uncontested evidence base was a necessary, but not sufficient condition for practice change, in that individual staff and patient responses such as caution influenced decision making. The implementation context was challenging, in which individuals and teams were bounded by professional issues, communication challenges, power and a lack of clarity for the authority and responsibility for practice change. Progress was made in sites where processes were aligned with existing initiatives. Additionally, facilitators reported engaging in many intervention implementation activities, some of which result in practice changes, but not significant improvements to outcomes.

Conclusions

This study provided an opportunity for reflection on the comprehensiveness of the PARIHS framework. Consistent with the underlying tenant of PARIHS, a multi-faceted and dynamic story of implementation was evident. However, the prominent role that individuals played as part of the interaction between evidence and context is not currently explicit within the framework. We propose that successful implementation of evidence into practice is a planned facilitated process involving an interplay between individuals, evidence, and context to promote evidence-informed practice. This proposal will enhance the potential of the PARIHS framework for explanation, and ensure theoretical development both informs and responds to the evidence base for implementation.

Trial registration

ISRCTN18046709 - Peri-operative Implementation Study Evaluation (PoISE).