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Kisembo HN, Malumba R, Sematimba H, Ankunda R, Nalweyiso ID, Malwadde EK, Rutebemberwa E, Kasasa S, Salama DH, Kawooya MG. Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework. Afr J Emerg Med 2024; 14:103-108. [PMID: 38756826 PMCID: PMC11096711 DOI: 10.1016/j.afjem.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs). Objectives The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored. Materials and Methods In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF. Results Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited. Conclusion Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.
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Affiliation(s)
- Harriet Nalubega Kisembo
- Makerere University, College of Health Sciences, School of Medicine
- Department of Radiology, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Richard Malumba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Henry Sematimba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Racheal Ankunda
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | | | - Elsie-Kiguli Malwadde
- African Centre for Global Health and Social Transformation (ACHEST), Kampala, Uganda
| | - Elizeus Rutebemberwa
- School of Public Health, Department of Health Policy & Management, Makerere University, Kampala, Uganda
| | - Simon Kasasa
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Michael Grace Kawooya
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
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Knight S, Rodda J, Tavender E, Anderson V, Lannin NA, Scheinberg A. Understanding factors that influence goal setting in rehabilitation for paediatric acquired brain injury: a qualitative study using the Theoretical Domains Framework. BRAIN IMPAIR 2024; 25:IB23103. [PMID: 38593747 DOI: 10.1071/ib23103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/14/2024] [Indexed: 04/11/2024]
Abstract
Background While goal setting with children and their families is considered best practice during rehabilitation following acquired brain injury, its successful implementation in an interdisciplinary team is not straightforward. This paper describes the application of a theoretical framework to understand factors influencing goal setting with children and their families in a large interdisciplinary rehabilitation team. Methods A semi-structured focus group was conducted with rehabilitation clinicians and those with lived experience of paediatric acquired brain injury (ABI). The 90-min focus group was audio-recorded and transcribed verbatim. Data were thematically coded and mapped against the Theoretical Domains Framework (TDF) to understand influencing factors, which were then linked to the Capability, Opportunity, Motivation - Behaviour (COM-B) model. Results A total of 11 participants (nine paediatric rehabilitation clinicians, one parent and one young person with lived experience of paediatric ABI) participated in the focus group. Factors influencing collaborative goal setting mapped to the COM-B and six domains of the TDF: Capabilities (Skills, Knowledge, Beliefs about capabilities, and Behavioural regulation), Opportunities (Environmental context and resources), and Motivation (Social/professional role and identity). Results suggest that a multifaceted intervention is needed to enhance rehabilitation clinicians' and families' skills and knowledge of goal setting, restructure the goal communication processes, and clarify the roles clinicians play in goal setting within the interdisciplinary team. Conclusion The use of the TDF and COM-B enabled a systematic approach to understanding the factors influencing goal setting for children with acquired brain injury in a large interdisciplinary rehabilitation team, and develop a targeted, multifaceted intervention for clinical use. These represent important considerations for the improvement of collaborative goal setting in paediatric rehabilitation services to ensure that best practice approaches to goal setting are implemented effectively in clinical practice.
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Affiliation(s)
- Sarah Knight
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Vic., Australia; and Melbourne School of Psychological Sciences, The University of Melbourne, Vic., Australia; and Department of Paediatrics, The University of Melbourne, Vic., Australia; and Victorian Paediatric Rehabilitation Service, The Royal Children's Hospital Melbourne, Vic., Australia
| | - Jill Rodda
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Emma Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Vicki Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Vic., Australia; and Melbourne School of Psychological Sciences, The University of Melbourne, Vic., Australia; and Department of Paediatrics, The University of Melbourne, Vic., Australia
| | - Natasha A Lannin
- Department of Neuroscience, Monash University, Melbourne, Vic., Australia; and Alfred Health, Melbourne, Vic., Australia
| | - Adam Scheinberg
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Vic., Australia; and Department of Paediatrics, The University of Melbourne, Vic., Australia; and Victorian Paediatric Rehabilitation Service, The Royal Children's Hospital Melbourne, Vic., Australia; and Department of Neuroscience, Monash University, Melbourne, Vic., Australia
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Trevena-Peters J, Ponsford J, McKay A. Implementation of activities of daily living retraining for individuals in post-traumatic amnesia. BRAIN IMPAIR 2024; 25:IB23093. [PMID: 38566296 DOI: 10.1071/ib23093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
Abstract
Background Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results Overall, the training workshop was rated as being helpful and OT ratings of confidence (P P Conclusion Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice.
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Affiliation(s)
- Jessica Trevena-Peters
- Monash University School of Psychological Sciences, Clayton, Vic., Australia; and Monash Epworth Rehabilitation Research Centre, Richmond, Vic., Australia
| | - Jennie Ponsford
- Monash University School of Psychological Sciences, Clayton, Vic., Australia; and Monash Epworth Rehabilitation Research Centre, Richmond, Vic., Australia; and Epworth Rehabilitation, Epworth HealthCare, Richmond, Vic., Australia
| | - Adam McKay
- Monash University School of Psychological Sciences, Clayton, Vic., Australia; and Monash Epworth Rehabilitation Research Centre, Richmond, Vic., Australia; and Epworth Rehabilitation, Epworth HealthCare, Richmond, Vic., Australia
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Hwang JHA, Downing MG, Specht RAG, Ponsford JL. Co-designing for behavioural change: understanding barriers and enablers to addressing sexuality after traumatic brain injury and mapping intervention strategies in a multi-disciplinary rehabilitation unit. BRAIN IMPAIR 2024; 25:IB23068. [PMID: 38566291 DOI: 10.1071/ib23068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/24/2023] [Indexed: 04/04/2024]
Abstract
Background Persistent changes in sexuality often follow traumatic brain injury (TBI). However, health professionals remain reticent about discussing sexuality and have reported barriers including uncertainties around whose role it is and limited educational and institutional support. This study employed a co-design and implementation process, aiming to promote team-wide behavioural change, whereby health professionals at a TBI rehabilitation unit would attempt to address sexuality with patients routinely. Methods Focus group sessions with multidisciplinary health professionals were conducted to identify barriers and enablers to behavioural change, identify areas for development, and co-design intervention options. Implementation deliverables were then finalised and provided to the team. The Theoretical Domains Framework was used to map factors influencing behaviours and the Behaviour Change Wheel was used to map interventions. Thematic analysis was used to further analyse barrier themes. Results Thirty-five barriers and eight enablers falling within 12 theoretical domains to behavioural change were identified. Thematic analysis revealed highly correlated barriers in initiating and sustaining change. Nine co-designed intervention options aligned with five intervention functions of the Behaviour Change Wheel, resulting in six final implementation deliverables. Conclusions Barriers were highly interrelated, influencing the approach to implementation deliverables. Simultaneously addressing multiple barriers could potentially alleviate discomfort associated with discussing sexuality. Concerns around initiating change were related to confidence in achieving sustainable changes. Achieving change requires organisational and team-level environmental restructuring and enablement. The next step involves evaluating the effectiveness of the co-design and implementation process in driving behavioural change and potential impacts on patient satisfaction and sexuality outcomes.
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Affiliation(s)
- Jill H A Hwang
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Vic. 3121, Australia; and Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, Vic. 3121 Australia
| | - Marina G Downing
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Vic. 3121, Australia; and Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, Vic. 3121 Australia
| | - Riccarda A G Specht
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Jennie L Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Vic. 3121, Australia; and Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, Vic. 3121 Australia
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Barry L, Tighe SM, Griffin A, Ryan D, O'Connor M, Fitzgerald C, Egan S, Galvin R, Meskell P. A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework. BMC Health Serv Res 2023; 23:1090. [PMID: 37821877 PMCID: PMC10568862 DOI: 10.1186/s12913-023-10027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/12/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021). METHODOLOGY A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively. FINDINGS This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators. TRIAL REGISTRATION PROSPERO: CRD42020188712 05/07/20.
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Affiliation(s)
- Louise Barry
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland.
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland.
| | - Sylvia Murphy Tighe
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Anne Griffin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Damien Ryan
- Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Christine Fitzgerald
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Siobhan Egan
- Clinical Research Support Unit, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Rose Galvin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Pauline Meskell
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Minian N, Saiva A, Ahad S, Gayapersad A, Zawertailo L, Veldhuizen S, Ravindran A, de Oliveira C, Mulder C, Baliunas D, Selby P. Primary healthcare provider experience of knowledge brokering interventions for mood management. Health Psychol Behav Med 2023; 11:2265136. [PMID: 37811314 PMCID: PMC10557557 DOI: 10.1080/21642850.2023.2265136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Background Knowledge brokering is a knowledge translation strategy used in healthcare settings to facilitate the implementation of evidence into practice. How healthcare providers perceive and respond to various knowledge translation approaches is not well understood. This qualitative study used the Theoretical Domains Framework to examine healthcare providers' experiences with receiving one of two knowledge translation strategies: a remote knowledge broker (rKB); or monthly emails, for encouraging delivery of mood management interventions to patients enrolled in a smoking cessation program. Methods Semi-structured interviews were conducted with 21 healthcare providers recruited from primary care teams. We used stratified purposeful sampling to recruit participants who were allocated to receive either the rKB, or a monthly email-based knowledge translation strategy as part of a cluster randomized controlled trial. Interviews were structured around domains of the Theoretical Domains Framework (TDF) to explore determinants influencing practice change. Data were coded into relevant domains. Results Both knowledge translation strategies were considered helpful prompts to remind participants to deliver mood interventions to patients presenting depressive symptoms. Neither strategy appeared to have influenced the health care providers on the domains we probed. The domains pertaining to knowledge and professional identity were perceived as facilitators to implementation, while domains related to beliefs about consequences, emotion, and environmental context acted as barriers and/or facilitators to healthcare providers implementing mood management interventions. Conclusion Both strategies served as reminders and reinforced providers' knowledge regarding the connection between smoking and depressed mood. The TDF can help researchers better understand the influence of specific knowledge translation strategies on healthcare provider behavior change, as well as potential barriers and facilitators to implementation of evidence-informed interventions. Environmental context should be considered to address challenges and facilitate the movement of knowledge into clinical practice.
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Affiliation(s)
- Nadia Minian
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
- Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Anika Saiva
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
| | - Sheleza Ahad
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
| | | | - Laurie Zawertailo
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
- Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Scott Veldhuizen
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
| | - Arun Ravindran
- Departments of Psychiatry & Pharmacology and Toxicology, University of Toronto, Toronto, Canada
- Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Cambell Family Mental Health Research Centre, Centre for Addiction and Mental Health, Toronto, Canada
| | - Claire de Oliveira
- Cambell Family Mental Health Research Centre, Centre for Addiction and Mental Health, Toronto, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Carol Mulder
- Department of Family Medicine, Queen’s University, Kingston, Canada
| | - Dolly Baliunas
- School of Public Health, University of Queensland, Herston, Australia
- Addictions, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Peter Selby
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Addictions Division and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Departments of Family and Community Medicine and Psychiatry, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Bragge P, Wright B, Grundy E, Goodwin D, Gozt A, Clynes L, Calabritto M, Fitzgerald M. What Happens Next? Traumatic Brain Injury in the Community. J Head Trauma Rehabil 2023; 38:279-282. [PMID: 36121684 DOI: 10.1097/htr.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury (TBI) continues to substantially impact the lives of millions of people around the world annually. Community-based prevention and support of TBI are particularly challenging and underresearched aspects of TBI management. Ongoing cognitive, emotional, and other effects of TBI are not immediately obvious in community settings such as schools, workplaces, sporting clubs, aged care facilities, and support agencies providing homelessness or domestic violence support. This is compounded by a lack of guidance and support materials designed for nonmedical settings. Connectivity Australia, a not-for-profit organization promoting TBI awareness, research, and support, responded to this need by conducting a national survey and series of roundtables to deepen understanding of TBI awareness, challenges, and support needs across the community. The 48 survey respondents and 22 roundtable participants represented Australian departments of health; correctional services; homelessness and housing; Aboriginal and Torres Strait Islander health; community, school, and professional sports; allied healthcare and rehabilitation providers; insurance; and work health and safety. Three key themes were identified: Accessible, nationally consistent plain-language guidelines ; Building research literacy ; and Knowing your role in TBI identification and management . This commentary briefly describes these themes and their implications based on a publicly available full report detailing the study findings ( www.connectivity.org.au/resources-for-researchers/connectivity-research ).
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Affiliation(s)
- Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Clayton Campus, Melbourne, Victoria, Australia (Drs Bragge, Wright, and Goodwin and Ms Grundy); Connectivity Traumatic Brain Injury Australia, Perth, Western Australia (Drs Gozt and Fitzgerald); Research Australia, the national peak body for Australian health and medical research, Sydney, Melbourne, and Canberra, Australia (Mss Clynes and Calabritto); Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia (Dr Fitzgerald); and Perron Institute for Neurological and Translational Science, Perth, Western Australia (Dr Fitzgerald)
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Tavender EJ, Wilson CL, Dalziel S, Oakley E, Borland M, Ballard DW, Cotterell E, Phillips N, Babl FE. Qualitative study of emergency clinicians to inform a national guideline on the management of children with mild-to-moderate head injuries. Emerg Med J 2023; 40:195-199. [PMID: 36002242 DOI: 10.1136/emermed-2021-212198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 08/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Head injury is a common reason children present to EDs. Guideline development to improve care for paediatric head injuries should target the information needs of ED clinicians and factors influencing its uptake. METHODS We conducted semi-structured qualitative interviews (November 2017-November 2018) with a stratified purposive sample of ED clinicians from across Australia and New Zealand. We identified clinician information needs, used the Theoretical Domains Framework (TDF) to explore factors influencing the use of head CT and clinical decision rules/guidelines in CT decision-making, and explored ways to improve guideline uptake. Two researchers coded the interview transcripts using thematic content analysis. RESULTS A total of 43 clinicians (28 doctors, 15 nurses), from 19 hospitals (5 tertiary, 8 suburban, 6 regional/rural) were interviewed. Clinicians sought guidance for scenarios including ED management of infants, children with underlying medical issues, delayed or representations and potential non-accidental injuries. Improvements to the quality and content of discharge communication and parental discussion materials were suggested. Known risks of radiation from head CTs has led to a culture of observation over use of CT in Australasia (TDF domain: beliefs about consequences). Formal and informal policies have resulted in senior clinicians making most head CT decisions in children (TDF domain: behavioural regulation). Senior clinicians consider their gestalt to be more accurate and outperform existing guidance (TDF domain: beliefs about capabilities), although they perceive guidelines as useful for training and supporting junior staff. Summaries, flow charts, publication in ED-specific journals and scripted training materials were suggestions to improve uptake. CONCLUSION Information needs of ED clinicians, factors influencing use of head CT in children with head injuries and the role of guidelines were identified. These findings informed the scope and implementation strategies for an Australasian guideline for mild-to-moderate head injuries in children.
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Affiliation(s)
- Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Departments of Surgery and Paediatrics, University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith Borland
- Emergency Department, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatrics and Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Dustin W Ballard
- CREST Network & Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, Tablelands Clinical School, University of New England, Armidale, New South Wales, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia .,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
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9
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Bradshaw S, Graco M, Holland A. Barriers and facilitators to guideline-recommended care of benign paroxysmal positional vertigo in the ED: a qualitative study using the theoretical domains framework. Emerg Med J 2023; 40:335-340. [PMID: 36792342 DOI: 10.1136/emermed-2022-212585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common presentation to the ED. Evidence suggests low adherence to guideline-recommended care, but the reasons underlying this are poorly understood. This study used the theoretical domains framework (TDF) to explore the barriers and facilitators to medical and physiotherapy clinical practices in the management of BPPV in an Australian metropolitan ED. METHODS From May to December 2021, semistructured interviews were conducted with 13 medical staff and 13 physiotherapists who worked at an ED in Melbourne, Australia. Interviews used the TDF to explore the perceived barriers and facilitators to the delivery of guideline-recommended assessment and treatment techniques for BPPV. Data were analysed thematically to identify relevant domains and generate themes and belief statements. RESULTS Fifteen belief statements representing eight domains of the TDF were identified as key factors in the management of BPPV in the ED. The most prominent domains were knowledge and skills due to their conflicting belief statements between professions concerning education, skill development and self-confidence; memory, attention and decision processes for the perceived complexity of the presentation including difficulty recalling diagnostic and treatment techniques; and environmental context and resources for their shared belief statements concerning time and workload pressures. The availability of vestibular physiotherapy was considered both a barrier and facilitator to the delivery of recommended care by medical staff, but a barrier to independent practice as it unintentionally limited the opportunities for skill development in medical staff. CONCLUSION Several modifiable barriers and facilitators to the management of BPPV in the ED have been identified. Differences were observed between the professional groups, and these findings will guide a future intervention to improve the use of guideline-recommended assessment and treatment techniques for BPPV in ED.
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Affiliation(s)
- Sally Bradshaw
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia .,School of Allied Health, La Trobe University, Bundoora Campus, Melbourne, Victoria, Australia.,Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Marnie Graco
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Respiratory Research, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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O’Brien SL, Haskell L, Tavender EJ, Wilson S, Borland ML, Oakley E, Dalziel SR, Gill FJ. Factors influencing health professionals' use of high-flow nasal cannula therapy for infants with bronchiolitis - A qualitative study. Front Pediatr 2023; 11:1098577. [PMID: 37009298 PMCID: PMC10060553 DOI: 10.3389/fped.2023.1098577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Aim To explore the factors influencing the use of high-flow nasal cannula (HFNC) therapy for infants with bronchiolitis. Design Qualitative approach using semi-structured interviews. Methods The semi-structured interviews (face-to-face or virtual) were conducted between September 2020 and February 2021. Deductive content analysis was used to map key influencing factors for use of HFNC therapy to the Theoretical Domains Framework (TDF). Results Nineteen interviews were undertaken before reaching thematic saturation (7 nurses, 12 doctors) in emergency departments and paediatric wards from four purposively selected hospitals in Australia and New Zealand. Influencing factors were mapped to eight domains in the TDF with 21 themes identified. Main findings included: (1) Health professionals' expectations of HFNC therapy on patient deterioration, work of breathing and oxygenation; (2) Staff emotions relating to concern and anxiety about deterioration and "need to do something"; (3) Social influences from other health professionals and parents and (4) Environmental factors relating to logistics of care and patient transfer considerations. These factors, combined with the ready availability of HFNC equipment and health professionals having the required skills to administer the therapy, contributed to its initiation. Conclusion Individual/personal and contextual/environmental factors contribute to the use of HFNC therapy for infants with bronchiolitis. It is evident these influences contribute substantially to increased use, despite evidence-based guidelines recommending a more nuanced approach to this therapy. These findings will inform a targeted implementation intervention to promote evidence-based use of HFNC therapy in infants with bronchiolitis.
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Affiliation(s)
- Sharon L. O’Brien
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Correspondence: Sharon L. O’Brien sharon.o’
| | - Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Sally Wilson
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Ed Oakley
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Emergency Department, Royal Children’s Hospital, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Fenella J. Gill
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- enAble Institute, Curtin University, Bentley, WA, Australia
- Nursing Research, Perth Children’s Hospital, Child & Adolescent Health Service, Nedlands, WA, Australia
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11
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Klaic M, Seng E, McGrath R. Factors that influence oral hygiene care with hospitalised stroke patients: a mixed methods study. Disabil Rehabil 2022; 44:7926-7935. [PMID: 34797190 DOI: 10.1080/09638288.2021.2003450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE Survivors of stroke experience poor oral health during and following hospitalisation. Health professionals consistently report that oral hygiene is complex. Interventions aiming to improve the delivery of oral hygiene care by health professionals rarely use a theoretically driven approach. This study reports the first phase in an intervention development and uses the action, actor, context, target, time (AACTT) framework and theoretical domains framework (TDF) to understand who needs to do what differently in the delivery of oral hygiene care with hospitalised stroke survivors. METHOD Mixed methods including analysis of oral health policies and clinical guidelines using the AACTT framework, focus group discussions using the TDF and audit of 60 medical records. RESULTS Policies and guidelines lack specificity regarding what oral hygiene care is and who should be responsible. Health professionals have low beliefs in their capabilities and experience numerous contextual barriers. More than 40% of patients had no documented evidence of oral hygiene care. CONCLUSION This study used a theoretically driven approach to identify barriers and enablers to health professional delivery of oral hygiene care with stroke survivors. Interventions aiming to improve clinical practice should target beliefs about capabilities, improved access to resources and detailed oral hygiene clinical guidelines.Implications for rehabilitationSurvivors of stroke experience poor oral health which can contribute to further strokes, cardiovascular disease and mortality.Health care professionals report difficulties in delivering oral hygiene care to hospitalised stroke survivors and clinical guidelines lack detail regarding oral health assessments, interventions and training.Interventions aiming to improve the delivery of oral hygiene care should target health professional beliefs about their capabilities using strategies such as behavioural practice.Resources specific to oral hygiene care for more complex patients, including suctioning toothbrushes, should be readily accessible for health professional use.Clinical guidelines and policies on oral hygiene care should include detail about training content, assessments tools and how to adapt information for patients with complex impairments.
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Affiliation(s)
- Marlena Klaic
- Allied Health Department, Royal Melbourne Hospital, Melbourne, Australia.,Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Erich Seng
- Melbourne Dental School, University of Melbourne, Melbourne, Australia
| | - Roisin McGrath
- Melbourne Dental School, University of Melbourne, Melbourne, Australia
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12
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Gangathimmaiah V, Evans R, Moodley N, Sen Gupta T, Drever N, Cardona M, Carlisle K. Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework. BMJ Open 2022; 12:e062755. [PMID: 36368755 PMCID: PMC9660707 DOI: 10.1136/bmjopen-2022-062755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. METHODS AND ANALYSIS A mixed methods scoping review using the Arksey and O'Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results. ETHICS AND DISSEMINATION Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Douglas, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry and Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Townsville Public Health Unit, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
- EBP Professorial Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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13
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ElChamaa R, Seely AJE, Jeong D, Kitto S. Barriers and Facilitators to the Implementation and Adoption of a Continuous Quality Improvement Program in Surgery: A Case Study. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 42:227-235. [PMID: 36215702 DOI: 10.1097/ceh.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION As postoperative adverse events (AEs) drive worsened patient experience, longer length of stay, and increased costs of care, surgeons have long sought to engage in innovative approaches aimed at reducing AEs to improve the quality and safety of surgical care. While data-driven AE performance measurement and feedback (PMF) as a form of continuing professional development (CPD) has been presented as a possible approach to continuous quality improvement (CQI), little is known about the barriers and facilitators that influence surgeons' engagement and uptake of these CPD programs. The purpose of this knowledge translation informed CPD study was to examine surgeons' perspectives of the challenges and facilitators to participating in surgical CQI with the broader objective of enhancing future improvements of such CPD interventions. METHODS Using Everett Rogers diffusion of innovations framework as a sampling frame, the participants were recruited across five surgical divisions. An exploratory case study approach, including in-depth semistructured interviews, was employed. Interview transcripts were analyzed and directly coded using the Theoretical Domains Framework. RESULTS Directed coding yielded a total of 527 coded barriers and facilitators to behavior change pertaining to the implementation and adoption of PMF with the majority of barriers and facilitators coded in four key theoretical domains environmental context and resources, social influences, knowledge, and beliefs about consequences. A key barrier was the lack of support from the hospital necessitating surgeons' self-funding their own PMF programs. Facilitators included having a champion to drive CQI and using seminars to facilitate discussions around CQI principles and practices. DISCUSSION This study identified multiple barriers and facilitators to surgeons' engagement and uptake of a data-driven PMF system in surgery. A key finding of the study was the identification of the influential role of positive deviance seminars as a quality improvement and patient safety mechanism that encourages surgeon engagement in PMF systems.
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Affiliation(s)
- Rima ElChamaa
- Ms. ElChamaa: Research Associate, Office of Continuing Professional Development, University of Ottawa, Ottawa, Ontario, Canada, and Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada. Mr. Seely: Professor of Surgery, Divisions of Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ontario, Canada, and Scientist, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Ms. Jeong: Research Associate, Office of Continuing Professional Development, University of Ottawa, Ottawa, Ontario, Canada, and Professor, Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada. Dr. Kitto: Director of Research, Office of Continuing Professional Development, University of Ottawa, Ottawa, Ontario, Canada, and Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
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14
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Tan E, Haskell L, Beck S, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments. J Paediatr Child Health 2022; 58:1847-1854. [PMID: 35869746 PMCID: PMC9796887 DOI: 10.1111/jpc.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/09/2022] [Accepted: 07/06/2022] [Indexed: 01/07/2023]
Abstract
AIM To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED. RESULTS About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources). CONCLUSIONS Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentsNorth Shore and Waitakere HospitalsAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical & Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
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15
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Wickbom F, Persson L, Olivecrona Z, Undén J. Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey. Scand J Trauma Resusc Emerg Med 2022; 30:35. [PMID: 35551626 PMCID: PMC9097395 DOI: 10.1186/s13049-022-01022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals. Methods This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0–17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020–March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable. Results 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006. Conclusions TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01022-4.
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Affiliation(s)
- Fredrik Wickbom
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden. .,Lund University, Lund, Sweden.
| | - Linda Persson
- Department of Orthopaedics, Halland Hospital, Halmstad, Sweden
| | - Zandra Olivecrona
- Department of Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
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16
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Bazarian JJ, Welch RD, Caudle K, Jeffrey CA, Chen JY, Chandran R, McCaw T, Datwyler SA, Zhang H, McQuiston B. Accuracy of a rapid glial fibrillary acidic protein/ubiquitin carboxyl-terminal hydrolase L1 test for the prediction of intracranial injuries on head computed tomography after mild traumatic brain injury. Acad Emerg Med 2021; 28:1308-1317. [PMID: 34358399 PMCID: PMC9290667 DOI: 10.1111/acem.14366] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective was to determine the accuracy of a new, rapid blood test combining measurements of both glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) for predicting acute traumatic intracranial injury (TII) on head CT scan after mild traumatic brain injury (mTBI). METHODS Analysis of banked venous plasma samples from subjects completing the Prospective Clinical Evaluation of Biomarkers of Traumatic Brain Injury (ALERT-TBI) trial, enrolled 2012-2014 at 22 investigational sites in the United States and Europe. All subjects were ≥18 years old, presented to an emergency department (ED) with a nonpenetrating head injury and Glasgow Coma Scale score (GCS) 9-15 (mild to moderate TBI), underwent head CT scanning as part of their clinical care, and had blood sampling within 12 h of injury. Plasma concentrations of GFAP and UCH-L1 were measured using i-STAT Alinity and TBI plasma cartridge and compared to acute TII on head CT scan. RESULTS Of the 2011 subjects enrolled in ALERT-TBI, 1918 had valid CT scans and plasma specimens for testing and 1901 (99.1%) had GCS 13-15 (mTBI), for which the rapid test was intended. Among these subjects, the rapid test had a sensitivity of 0.958 (95% confidence interval [CI] = 0.906 to 0.982), specificity of 0.404 (95% CI = 0.382 to 0.427), negative predictive value of 0.993 (95% CI = 0.985 to 0.997), and positive predictive value of 0.098 (95% CI = 0.082 to 0.116) for acute TII. CONCLUSIONS A rapid i-STAT-based test had high sensitivity for prediction of acute TII, comparable to lab-based platforms. The speed, portability, and high accuracy of this test may facilitate clinical adoption of brain biomarker testing as an aid to head CT decision making in EDs.
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Affiliation(s)
- Jeffrey J. Bazarian
- Departments of Emergency Medicine and Neurology University of Rochester Rochester New York USA
| | - Robert D. Welch
- Department of Emergency Wayne State University School of Medicine Detroit Michigan USA
- Biostatistics and Epidemiology Research Design Core Wayne State University Detroit Michigan USA
| | - Krista Caudle
- Warfighter Brain Health Project Management OfficeUS Army Medical Materiel Development Activity, US Army Medical Research and Development Command Fort Detrick Maryland USA
| | | | - James Y. Chen
- Department of Radiology San Diego Veterans Administration Medical Center La Jolla California USA
- Department of Radiology UC San Diego Health System La Jolla California USA
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Silverberg ND, Otamendi T, Dulai A, Rai R, Chhina J, MacLellan A, Lizotte PP. Barriers and facilitators to the management of mental health complications after mild traumatic brain injury. Concussion 2021; 6:CNC92. [PMID: 34408906 PMCID: PMC8369524 DOI: 10.2217/cnc-2020-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI. Methods & results: Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains. Conclusion: Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists. Best practice recommendations call for family doctors to proactively screen for and treat mental health problems that might arise after a mild traumatic brain injury (mTBI) (also known as a concussion). However, previous studies show that these recommendations are not followed consistently. The authors aimed to find reasons why this is not happening by interviewing 11 family doctors. The authors found that family doctors are mostly unaware of resources to guide their practice, are unsure about their role in mental health management, and experience difficulties in referring their patients to specialists for mental health care. Actively providing family doctors with knowledge and tools that help them initiate mental health care, as well as a structure for mental health referrals after mild traumatic brain injury, would help doctors apply best practice recommendations.
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Affiliation(s)
- Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 2G9, Canada
| | - Thalia Otamendi
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 2G9, Canada
| | - Amanda Dulai
- Department of Family Practice, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Ripenjot Rai
- Department of Family Practice, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Jason Chhina
- Department of Family Practice, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Anna MacLellan
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 2G9, Canada
| | - Pierre-Paul Lizotte
- Department of Family Practice, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.,Department of Family Medicine, Providence Health Care, Vancouver, BC, V6Z 1Y6, Canada
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18
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Dyson J, Cowdell F. How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review. Int J Qual Health Care 2021; 33:6324052. [PMID: 34279637 DOI: 10.1093/intqhc/mzab106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/21/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice. OBJECTIVE The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions. METHODS We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis. RESULTS A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable. CONCLUSION Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.
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Affiliation(s)
- Judith Dyson
- Healthcare Research and Implementation Science, Faculty of Health, Education and Life Sciences, Birmingham City University, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK
| | - Fiona Cowdell
- Faculty of Health, Education and Life Sciences, Nursing and Healthcare Research, Birmingham City University, Westbourne Road, Birmingham B15 3TN, UK
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Rashid H, Mishra S, Dobbin N. Management of sport-related concussion in emergency departments in England: a multi-center study. Brain Inj 2021; 35:1035-1042. [PMID: 34288793 DOI: 10.1080/02699052.2021.1945146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To establish the current knowledge of sport-related concussion (SRC) management of clinicians in emergency departments in the North West of England. METHODS A cross-sectional, multi-center study design was used and included emergency department clinicians (EDCs) across 15 centers in the North West of England. A 22-question survey was issued with questions focused on the 5th International Conference on Concussion Consensus Statement. Absolute and percentages were presented, and comparisons in knowledge of guidelines and confidence between EDCs were made using the Kruskal-Wallis test. RESULTS Of an estimated 300 EDCs, 111 (37%) responded. Thirty (27%) were aware of the guidelines, whilst 63 (57%) had heard of a graduated return-to-sport protocol. Physical rest was advised by 106 (95%) respondents, with 68 (61%) advising cognitive rest and 47 (42%) providing written advice. There was no difference (p > .05) in awareness of SRC guidelines or confidence between clinician grade, with most receiving no SRC training. CONCLUSIONS There is a lack of knowledge amongst EDCs in the North West of England in managing and providing discharge advice to patients with SRC. This is likely due to the limited awareness of guidelines and training, and therefore further education delivery on SRC management guidelines is required.
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Affiliation(s)
- Haroon Rashid
- Department of Emergency Medicine, Manchester Royal Infirmary, Manchester, UK.,Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Smarak Mishra
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Nick Dobbin
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
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Toomey M, Gyawali R, Stapleton F, Ho KC, Keay L, Jalbert I. Facilitators and barriers to the delivery of eye care by optometrists: a systematic review using the theoretical domains framework. Ophthalmic Physiol Opt 2021; 41:782-797. [PMID: 33774856 DOI: 10.1111/opo.12801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/21/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Evidence-based practice is fundamental to providing quality care, patient satisfaction and judicious use of limited healthcare resources. However, variability in evidence-based eye care delivery has been reported. Given the important role of optometrists in delivering primary eye care, a better understanding of the barriers and facilitators to providing optometric care is required. This systematic review aimed to identify determinants (barriers and facilitators) of eye care delivery by optometrists and interventions that may improve eye care delivery. RECENT FINDINGS PubMed, MEDLINE, EMBASE, CINAHL, SCOPUS, PsychINFO, ProQuest and Web of Science were searched for studies reporting barriers and facilitators to eye care delivery published between 1999 and 2020. The Theoretical Domains Framework (TDF) was used to analyse data (quotations, interpretive summaries, survey result) with barriers and facilitators coded to one or more of the 14 domains, and used to identify the key behavioural domains influencing eye care delivery based on frequency of coding, elaboration and stated importance in the study. Influential domains were mapped to the Behaviour Change Wheel to identify potential interventions to improve eye care delivery. Of the 802 studies retrieved from the search, 30 were included. Frequently identified barriers were time constraints, resources and equipment issues, patient factors, lack of awareness, skill proficiency deficits and negative attitudes and beliefs. Frequently identified facilitators were adequate time, resources and equipment, education, skill proficiency and understanding the relevancy of the eye care provided. The key TDF domains influencing eye care delivery were 'environmental context and resources' (time, resources, equipment issues, patient factors), 'knowledge' (awareness issues), 'skills' (skills proficiency) and 'belief about consequences' (beliefs and relevancy). Intervention functions that may improve eye care delivery were education, training, restriction, environmental restructuring, enablement, persuasion and modelling. SUMMARY The barriers and facilitators identified in this review were diverse and located at both the practitioner and organisational levels. Four TDF domains were found to be influential determinants of eye care practice. Intervention functions identified in this study can be used to improve the appropriateness of primary eye care delivery.
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Affiliation(s)
- Melinda Toomey
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Rajendra Gyawali
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Fiona Stapleton
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Kam Chun Ho
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lisa Keay
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Isabelle Jalbert
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
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Kanazaki R, Smith B, Girgis A, Descallar J, Connor S. Survey of barriers to adherence to international inflammatory bowel disease guidelines: Does gastroenterologists' confidence translate to high adherence? Intern Med J 2021; 52:1330-1338. [PMID: 33755298 DOI: 10.1111/imj.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND & AIMS Despite the availability of evidence-based inflammatory bowel disease (IBD) guidelines, suboptimal care persists. There is little published research assessing barriers to IBD guideline adherence. This study aimed to identify barriers to IBD guideline adherence including gastroenterologists' knowledge and attitudes towards guidelines. METHODS An online cross-sectional survey of 824 Australian gastroenterologists was conducted from April to August 2018, with 198 (24%) responses. A novel survey was developed which was informed by the theoretical domain's framework. RESULTS Confidence in guideline recommendations was high, however referral to them was low. The European Crohn's and Colitis Organisation (ECCO) guidelines were the most commonly referred to (43.6%). In multivariate analysis, significant predictors of frequent versus infrequent guideline referral were: high confidence in the guideline (OR 7.70, 95% CI: 2.43-24.39, p = 0.001), and low (≤10 years) clinical experience (OR 3.62, 95% CI: 1.11-11.79, p = 0.03). The most common barriers to guideline adherence were not having time (62%) followed by guideline specifics being difficult to remember (61%). Low confidence was reported in managing pregnancy and IBD (34%) and loss of response to therapy (29%). High confidence was reported in managing immunomodulators, however only 43% answered the associated knowledge question correctly. CONCLUSION Although gastroenterologists' have high confidence in guidelines, they use them infrequently, primarily due to specifics being difficult to remember and lack of time. Self-reported confidence in an area of IBD management does not always reflect knowledge. An intervention targeting these barriers, for example computer-based clinical decision support tools, may improve adherence and standardise care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ria Kanazaki
- South Western Sydney Clinical School, University of New South Wales, Australia
| | - Ben Smith
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Afaf Girgis
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Joseph Descallar
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia.,Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
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Barry L, Galvin R, Murphy Tighe S, O'Connor M, Ryan D, Meskell P. The barriers and facilitators to implementing screening in emergency departments: a qualitative evidence synthesis (QES) protocol exploring the experiences of healthcare workers. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13073.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Screening in the emergency department (ED) can identify individuals in need of targeted assessment and early intervention in the hospital or community setting. Time pressures, inadequate resources, poor integration of screening tools into clinical workflow and lack of staff training are barriers to successfully implementing screening in the ED. Tailored implementation processes and education programmes were identified as facilitators. The aim of this QES is to synthesise evidence pertaining to the barriers and facilitators to implementing screening in the ED. This review will focus on the experience of healthcare workers (HCWs) who are involved in this process. Methods: A comprehensive literature search will be completed in Scopus, CINAHL, Medline, Embase, Pubmed and Cochrane library. Grey literature sources will be searched and include Open Grey, Google Scholar, Lenus Irish Health Repository, Science.Gov and Embase Grey Literature. Qualitative or mixed methods studies that include qualitative data on the experiences of HCWs will be included. “Best fit” framework synthesis will be utilised to produce a context specific conceptual model to describe and explain how these barriers and facilitators may impact on implementation. An a priori framework of themes, formed from the existing evidence base, will inform the ultimate thematic analysis and assist in the organisation and interpretation of search results, ensuring the QES is built upon current findings. CASP will be utilised to quality appraise articles and GRADE CERQual will assess confidence in the QES findings. The screening, quality appraisal, data extraction and assessment of confidence in findings will be completed by two reviewers independently and in duplicate. Contingencies for conflict management during these processes will be outlined. Conclusions: This synthesis, will offer a new conceptual model for describing healthcare workers’ experience of the barriers and facilitators that impact on the implementation of screening tools in the ED. Registration: PROSPERO CRD42020188712 05/07/20
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McInnes E, Dale S, Craig L, Phillips R, Fasugba O, Schadewaldt V, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, Considine J, McElduff P, Gerraty R, Fitzgerald M, Ward J, D’Este C, Middleton S. Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T 3 trial): a qualitative study. Implement Sci 2020; 15:99. [PMID: 33148343 PMCID: PMC7640433 DOI: 10.1186/s13012-020-01057-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. METHODS Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. RESULTS Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. CONCLUSIONS Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).
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Affiliation(s)
- Elizabeth McInnes
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Level 4, Daniel Mannix Building, Brunswick Street, Fitzroy, Victoria 3065 Australia
| | - Simeon Dale
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, Victoria Street, Darlinghurst, New South Wales 2010 Australia
| | - Louise Craig
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, Victoria Street, Darlinghurst, New South Wales 2010 Australia
| | - Rosemary Phillips
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, Victoria Street, Darlinghurst, New South Wales 2010 Australia
| | - Oyebola Fasugba
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 2, Signadou Building, Australian Catholic University, 223 Antill Street, Watson, Australian Capital Territory 2602 Australia
| | - Verena Schadewaldt
- Department of Neurosurgery, University of Melbourne and Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050 Australia
- Formerly: Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Victoria, Australia
| | - N. Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead, Sydney, New South Wales Australia
| | - Dominique A. Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria Australia
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital – General Campus, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Room 1286, Ottawa, Ontario K1H 8 L6 Canada
- Department of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8 M5 Canada
| | - Chris Levi
- The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Liverpool, New South Wales Australia
| | - Julie Considine
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria 3220 Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales Australia
| | - Richard Gerraty
- Department of Medicine, Monash University, Melbourne, Victoria 3800 Australia
- Neurosciences Clinical Institute, Epworth Hospital, Richmond, Victoria 3121 Australia
| | - Mark Fitzgerald
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria 3800 Australia
- Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia
| | - Jeanette Ward
- Nulungu Research Institute, University of Notre Dame Australia, Broome, Western Australia Australia
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australian Capital Territory 0200 Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales 2308 Australia
| | - Sandy Middleton
- Nursing Research Institute - St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, Victoria Street, Darlinghurst, New South Wales 2010 Australia
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Barry L, Galvin R, Murphy Tighe S, O'Connor M, Ryan D, Meskell P. The barriers and facilitators to screening in emergency departments: a qualitative evidence synthesis (QES) protocol. HRB Open Res 2020. [DOI: 10.12688/hrbopenres.13073.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Early detection of adults at risk of adverse outcomes through systematic screening in the emergency department (ED) can serve to identify high risk groups in need of targeted assessment and early intervention in the hospital or community setting. However, issues such as time pressures, inadequate resources, poor integration of tools into clinical workflow and lack of staff training are cited among the barriers to successfully implementing screening tools in the ED. The aim of this qualitative evidence synthesis (QES) is to synthesize evidence pertaining to the barriers and facilitators to implementing screening tools in the ED. Methods: A comprehensive literature search will be completed in the following databases Scopus, CINAHL, Medline, Embase, Pubmed and Cochrane library. Grey literature sources will also be searched. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of stakeholders on the implementation of screening tools in the ED will be included. “Best fit” framework synthesis will be utilised to produce a context specific conceptual model to describe and explain how these barriers and facilitators may impact on implementation. An a priori framework of themes, formed from the existing evidence base, will inform the ultimate thematic analysis and assist in the organisation and interpretation of search results, ensuring the QES is built upon current findings. CASP will be utilised to quality appraise articles and GRADE CERQual will assess confidence in the QES findings. Conclusions: This synthesis will offer a new conceptual model for describing the perspectives, perceptions and experiences of barriers and facilitators experienced by patients and key stakeholders involved in the implementation of screening tools in the ED. The results of this review will inform practice and aid the development and implementation of change strategies to support the implementation of screening tools in the ED. Registration: PROSPERO CRD42020188712 05/07/20
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25
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Haskell L, Tavender EJ, Wilson C, Babl FE, Oakley E, Sheridan N, Dalziel SR. Understanding factors that contribute to variations in bronchiolitis management in acute care settings: a qualitative study in Australia and New Zealand using the Theoretical Domains Framework. BMC Pediatr 2020; 20:189. [PMID: 32357866 PMCID: PMC7193400 DOI: 10.1186/s12887-020-02092-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 04/20/2020] [Indexed: 11/20/2022] Open
Abstract
Background Bronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework. Methods Semi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis. Results Between July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse’s reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of ‘paediatric confident’ nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources). Conclusions Factors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | - Ed Oakley
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | | | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Jones CMC, Harmon C, McCann M, Gunyan H, Bazarian JJ. S100B outperforms clinical decision rules for the identification of intracranial injury on head CT scan after mild traumatic brain injury. Brain Inj 2020; 34:407-414. [PMID: 32064945 DOI: 10.1080/02699052.2020.1725123] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To compare the classification accuracy of S100B to two clinical decision rules- Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC)-for predicting traumatic intracranial injuries (ICI) after mild traumatic brain injury (mild TBI).Methods: A secondary analysis of a prospective observational study of mild TBI patients was performed. The diagnostic performance of S100B for predicting ICI on head CT was compared to both the CHRR and NOC. Area under receiver operator characteristic (AUC) curves were used and multivariable analysis was used to create a new decision rule based on a combination of S100B and decision rule-related variables.Results: S100B had the highest negative predictive value (97.3%), positive predictive value (7.21%), specificity (33.6%) and positive likelihood ratio (1.3), and the lowest negative likelihood ratio (0.5). The proportion of mild TBI subjects with potentially avoidable head CT scans was highest using S100B (37.7%). The addition of S100B to both clinical decision rules significantly increased AUC. A novel decision rule adding S100B to three decision rule-related variables significantly improved prediction (p < 0.05).Conclusion: Serum S100B outperformed clinical decision rules for identifying mild TBI patients with ICI. Incorporating clinical variables with S100B maximized ICI prediction, but requires validation in an independent cohort.
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Affiliation(s)
- Courtney Marie Cora Jones
- Departments of Emergency Medicine, Orthopaedics, and Public Health Sciences, University of Rochester, School of Medicine and Dentistry, Rochester, New York, USA
| | - Christopher Harmon
- Department of Emergency Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, New York, USA
| | - Molly McCann
- Departments of Public Health Sciences and Emergency Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, New York, USA
| | - Holly Gunyan
- SMHC Emergency Department, One Medical Center Drive, Biddeford, Maine, USA
| | - Jeffrey J Bazarian
- Departments of Emergency Medicine, Neurology, Neurosurgery, Public Health Sciences and Physical Medicine and Rehabilitation, University of Rochester, School of Medicine and Dentistry, Rochester, New York, USA
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Dogba MJ, Brent MH, Bach C, Asad S, Grimshaw J, Ivers N, Légaré F, Witteman HO, Squires J, Wang X, Sutakovic O, Zettl M, Drescher O, van Allen Z, McCleary N, Tremblay MC, Linklater S, Presseau J. Identifying Barriers and Enablers to Attending Diabetic Retinopathy Screening in Immigrants to Canada From Ethnocultural Minority Groups: Protocol for a Qualitative Descriptive Study. JMIR Res Protoc 2020; 9:e15109. [PMID: 32049067 PMCID: PMC7055809 DOI: 10.2196/15109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/26/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
Background Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness. Objective This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance. Methods The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains. Results This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020. Conclusions Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening. International Registered Report Identifier (IRRID) DERR1-10.2196/15109
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Affiliation(s)
| | | | - Catherine Bach
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Sarah Asad
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Noah Ivers
- Women's Health College, Toronto, ON, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Holly O Witteman
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Janet Squires
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Xiaoqin Wang
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Mary Zettl
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Olivia Drescher
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Zack van Allen
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Nicola McCleary
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Claude Tremblay
- Department of Family Medicine and Emergency Medicine, Laval Unviersity, Québec, QC, Canada
| | - Stefanie Linklater
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Justin Presseau
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Shrubsole K. Implementation of an integrated multidisciplinary Movement Disorders Clinic: applying a knowledge translation framework to improve multidisciplinary care. Disabil Rehabil 2019; 43:2071-2083. [PMID: 31741400 DOI: 10.1080/09638288.2019.1691666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the implementation of an integrated multidisciplinary Movement Disorder Clinic using a model of knowledge translation. METHODS A mixed methods design was used to evaluate implementation outcomes. After recognising poor referral rates to allied health, Movement Disorder Clinic team-members identified implementation barriers. Team- and process-level implementation strategies were designed and tailored to address these barriers. The primary outcome measure was the change in the proportion of patients referred to allied health, determined by comparing pre- and post-implementation documentation audits. Secondary outcome measures included clinician and consumer surveys to identify ongoing implementation barriers and stakeholder satisfaction. RESULTS Documentation from 90 medical records was included in the audits (post-intervention n = 45). There was a significant improvement in the referral rates to allied health from 53% to 84% (mean improvement 31%, p = 0.003, Fisher's exact test). However, documentation of disease education decreased by 38% (p = 0.000, Fisher's exact test). Movement Disorder Clinic team-members identified three main barriers to ongoing implementation: "memory and automaticity", "environmental context and resources" and "beliefs about capabilities". Thirty-seven consumer surveys were completed, showing high levels of satisfaction (86%) but ongoing educational needs (51%). CONCLUSIONS Implementation of an integrated multidisciplinary Movement Disorder Clinic was facilitated by a knowledge translation framework, leading to improved allied health referral rates and high levels of staff and consumer satisfaction, but unmet educational needs of consumers. Future research in the field of multidisciplinary healthcare for people with movement disorders is needed to determine the impact of these changes on patients' healthcare outcomes.Implications for rehabilitationMultidisciplinary integrated healthcare models may lead to better outcomes in progressive diseases such as Parkinson's disease, however, can be challenging to implement.A knowledge translation framework facilitated successful implementation of an integrated multidisciplinary Movement Disorders Clinic, leading to significantly improved rates of appropriate referrals to allied health, and staff and consumer satisfaction.Team-members identified three main barriers to ongoing implementation - "memory and automaticity", "environmental context and resources," and "beliefs about capabilities" - which may impact sustainability and should be considered in future implementation efforts.
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Affiliation(s)
- Kirstine Shrubsole
- School of Health and Human Sciences, Southern Cross University, Gold Coast, Queensland, Australia
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29
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Concussion in Combination With Whiplash-Associated Disorder May Be Missed in Primary Care: Key Recommendations for Assessment and Management. J Orthop Sports Phys Ther 2019; 49:819-828. [PMID: 31610758 DOI: 10.2519/jospt.2019.8946] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Whiplash and concussion may have similar presenting symptoms, biomechanical mechanisms, and neurophysiological sequelae, but neither enjoys a gold standard diagnostic test. Guidelines for whiplash and concussion are developed and implemented separately. This disparate process may contribute to misdiagnosis, delay appropriate primary care management, and impair patient outcomes. In our clinical commentary, we present 3 cases where signs and symptoms consistent with whiplash were identified in primary care. Symptoms in all cases included neck pain, headache, dizziness, and concentration deficits, raising suspicion of coexisting postconcussion syndrome. All cases were referred for specialist physical therapy. Characteristics consistent with poor recovery in both whiplash and postconcussion syndrome were confirmed, and multidisciplinary management, drawing from both whiplash and concussion guidelines, was implemented. All patients reported improvement in activities of daily living after tailored management addressing both neck and head injury-related factors, suggesting that these conditions were not mutually exclusive. Self-reported outcomes included reductions in neck disability and postconcussion symptoms of between 20% and 40%. It may be appropriate for whiplash and concussion guidelines to be amalgamated, enhanced, and mutually recognized on a patient-by-patient basis. Primary health care professionals might consider minimum screening to identify postconcussion syndrome in patients following motor vehicle collision by administering questionnaires and assessing cranial nerve function, balance, and cognition. Management should then incorporate principles from both whiplash and concussion guidelines and harmonize with available imaging guidelines for suspected spine and head trauma. J Orthop Sports Phys Ther 2019;49(11):819-828. doi:10.2519/jospt.2019.8946.
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Searle K, Blashki G, Kakuma R, Yang H, Zhao Y, Minas H. Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders. Int J Ment Health Syst 2019; 13:47. [PMID: 31297142 PMCID: PMC6598358 DOI: 10.1186/s13033-019-0300-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/11/2019] [Indexed: 01/03/2023] Open
Abstract
Background The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community. Methods Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations. Results Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital. Conclusions Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence.
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Affiliation(s)
- Kendall Searle
- 1Global and Cultural Mental Health Unit, Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC 3010 Australia
| | - Grant Blashki
- 2Nossal Institute for Global Health, The University of Melbourne, Melbourne, VIC 3010 Australia
| | - Ritsuko Kakuma
- 3London School of Hygiene and Tropical Medicine, London, WC1E 7HTE England UK
| | - Hui Yang
- 4Monash Institute for Health & Clinical Education, School of Primary Health Care, Monash University, Notting Hill, VIC 3168 Australia
| | - Yuanlin Zhao
- 5Faculty of Education, Queen's University, Kingston, ON Canada
| | - Harry Minas
- 1Global and Cultural Mental Health Unit, Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC 3010 Australia
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Barker A, Doeltgen S, Lynch E, Murray J. Perceived barriers and enablers for implementing water protocols in acute stroke care: A qualitative study using the Theoretical Domains Framework. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 21:286-294. [PMID: 31213158 DOI: 10.1080/17549507.2019.1595145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 02/27/2019] [Accepted: 03/09/2019] [Indexed: 06/09/2023]
Abstract
Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings. Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework. Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation. Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.
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Affiliation(s)
- Allison Barker
- a College of Nursing and Health Sciences, Flinders University , Adelaide , Australia
| | - Sebastian Doeltgen
- b Swallowing Neurorehabilitation Research Laboratory, College of Nursing and Health Sciences, Flinders University , Adelaide Australia
| | - Elizabeth Lynch
- c Adelaide Nursing School University of Adelaide & NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health
| | - Joanne Murray
- a College of Nursing and Health Sciences, Flinders University , Adelaide , Australia
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To TP, Dunnachie G, Brien JA, Story DA. Surgical nurses' perceptions and experiences of a medications and oral restrictions policy change: A focus group study. J Clin Nurs 2019; 28:3242-3251. [PMID: 31013378 DOI: 10.1111/jocn.14898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/10/2019] [Accepted: 04/14/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore the perceptions and experiences of surgical nurses before and after introducing the Medications and Oral Restrictions Policy (the Policy). BACKGROUND The Policy was developed following extensive consultation, and evidence-based strategies were considered for its implementation. However, it is possible uptake did not meet expectations. DESIGN Focus group interviews. METHODS Three focus groups were conducted in November 2015 around 'what worked, what didn't and why, before and after hospital-wide implementation of the Policy.' Data were coded and analysed using an inductive-deductive thematic analysis approach. The COREQ checklist guided reporting. RESULTS The three groups consisted of 16, 14 and six surgical nurses. Before the Policy, there was confusion, lack of clarity and guidance, and lack of experience and confidence in managing medications when patients had oral restrictions. After the Policy rollout, there was a sense of 'knowing what to do' because of improved clarity and decision support; but there were also problems with: not everyone knowing about the policy, particularly due to staff movement and turnover; and, individual interpretation of the policy including use of its signs outside of context, and decision-making processes. CONCLUSION Exploration of nurses' perceptions of a medication-related policy change found that while the Policy provided clarity and decision support for some, it made little difference for others. Limited reach of the policy was an issue despite an effort to address this at the outset, as well as variations in interpretation of the policy and subsequent decision-making. RELEVANCE TO CLINICAL PRACTICE How individuals interpret information and their understanding of the context behind the policy or guideline may affect implementation and should be considered alongside other barriers when implementing medication-related initiatives. Furthermore, implementation strategies that are independent of ongoing resources and/or key champions to sustain should be prioritised for all initiatives.
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Affiliation(s)
- The-Phung To
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gillian Dunnachie
- Surgical Clinical Service Unit, Austin Health, Melbourne, Victoria, Australia
| | - Jo-Anne Brien
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine, St Vincent's Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - David A Story
- Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Tavender E, Babl FE, Middleton S. Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction. Emerg Med Australas 2019; 31:332-338. [DOI: 10.1111/1742-6723.13296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Melbourne, Victoria Australia
- Department of PaediatricsThe University of Melbourne Melbourne Victoria Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Melbourne, Victoria Australia
- Department of PaediatricsThe University of Melbourne Melbourne Victoria Australia
- Emergency DepartmentThe Royal Children's Hospital Melbourne Victoria Australia
| | - Sandy Middleton
- Nursing Research InstituteSt Vincent's Health Australia and Australian Catholic University Sydney New South Wales Australia
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Murray-Torres T, Casarella A, Bollini M, Wallace F, Avidan MS, Politi MC. Anesthesiology Control Tower-Feasibility Assessment to Support Translation (ACTFAST): Mixed-Methods Study of a Novel Telemedicine-Based Support System for the Operating Room. JMIR Hum Factors 2019; 6:e12155. [PMID: 31012859 PMCID: PMC6658281 DOI: 10.2196/12155] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 01/26/2023] Open
Abstract
Background Despite efforts to improve patient outcomes, major morbidity and mortality remain common after surgery. Health information technologies that provide decision support for clinicians might improve perioperative and postoperative patient care. Evaluating the usability of these technologies and barriers to their implementation can facilitate their acceptance within health systems. Objective This manuscript describes usability testing and refinement of an innovative telemedicine-based clinical support system, the Anesthesiology Control Tower (ACT). It also reports stakeholders’ perceptions of the barriers and facilitators to implementation of the intervention. Methods Three phases of testing were conducted in an iterative manner. Phase 1 testing employed a think-aloud protocol analysis to identify surface-level usability problems with individual software components of the ACT and its structure. Phase 2 testing involved an extended qualitative and quantitative real-world usability analysis. Phase 3 sought to identify major barriers and facilitators to implementation of the ACT through semistructured interviews with key stakeholders. Results Phase 1 and phase 2 usability testing sessions identified numerous usability problems with the software components of the ACT. The ACT platform was revised in seven iterations in response to these usability concerns. Initial satisfaction with the ACT, as measured by standardized instruments, was below commonly accepted cutoffs for these measures. Satisfaction improved to acceptable levels over the course of revision and testing. A number of barriers to implementation were also identified and addressed during the refinement of the ACT intervention. Conclusions The ACT model can improve the standard of perioperative anesthesia care. Through our thorough and iterative usability testing process and stakeholder assessment of barriers and facilitators, we enhanced the acceptability of this novel technology and improved our ability to implement this innovation into routine practice. International Registered Report Identifier (IRRID) RR2-10.1186/s40814-018-0233-4
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Affiliation(s)
- Teresa Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Aparna Casarella
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Mara Bollini
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Frances Wallace
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
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Curran JA, Gallant AJ, Zemek R, Newton AS, Jabbour M, Chorney J, Murphy A, Hartling L, MacWilliams K, Plint A, MacPhee S, Bishop A, Campbell SG. Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis. Syst Rev 2019; 8:83. [PMID: 30944038 PMCID: PMC6446263 DOI: 10.1186/s13643-019-0995-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/22/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research. METHODS We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings. RESULTS A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice. CONCLUSION Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42014007106.
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Affiliation(s)
- Janet A. Curran
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Allyson J. Gallant
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Roger Zemek
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Amanda S. Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Jill Chorney
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Murphy
- College of Pharmacy, Dalhousie University, 5869 University Avenue, PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Kate MacWilliams
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Amy Plint
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Shannon MacPhee
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Samuel G. Campbell
- Charles V. Keating Emergency and Trauma Centre, QEII Health Sciences Centre, 1796 Summer St, Halifax, NS B3H 3A7 Canada
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Fingleton N, Duncan E, Watson M, Matheson C. Specialist Clinicians' Management of Dependence on Non-Prescription Medicines and Barriers to Treatment Provision: An Exploratory Mixed Methods Study Using Behavioural Theory. PHARMACY 2019; 7:E25. [PMID: 30841493 PMCID: PMC6473901 DOI: 10.3390/pharmacy7010025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/15/2019] [Accepted: 02/28/2019] [Indexed: 12/01/2022] Open
Abstract
The aim of the study was to establish how non-prescription medicine (NPM) dependence is treated by doctors in specialist substance misuse treatment services and to identify perceived barriers to providing treatment. An online survey was conducted to establish current practice and whether changes to service provision are needed to facilitate treatment (n = 83). Semi-structured interviews, based on the Theoretical Domains Framework, were conducted to derive a detailed exploration of suggested changes (n = 11). Most survey respondents had encountered cases of NPM dependence. Analgesics containing codeine were the most frequently NPMs of dependence mentioned by respondents. Most respondents were unaware of specific guidelines for the treatment of NPM dependence. The most frequently identified barriers to providing treatment identified by interviewees were limited resources or capacity and the challenges presented by this client group. There was a perception that this client group could be difficult to treat due to comorbidities, and these this client group perceived themselves to be different from people dependent on alcohol or illicit drugs. This study identified a clear need for specific clinical guidelines for the treatment of NPM dependence. Such guidance should be appropriate for specialist and generalist clinicians as the current pressure on resources may force more treatment into general practice. Appropriate care pathways need to be established and defined, and sufficient resources allocated to accommodate this client group.
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Affiliation(s)
- Niamh Fingleton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Margaret Watson
- Department of Pharmacy and Pharmacology, University of Bath, Bath BA2 7AY, UK.
| | - Catriona Matheson
- Faculty of Social Sciences, University of Stirling, Stirling FK9 4LA, UK.
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Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L. Addressing unwarranted clinical variation: A rapid review of current evidence. J Eval Clin Pract 2019; 25:53-65. [PMID: 29766616 DOI: 10.1111/jep.12930] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness. DESIGN Rapid evidence assessment (REA) methodology was used. DATA SOURCES A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature. DATA SYNTHESIS Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature. RESULTS A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV. CONCLUSION Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.
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Affiliation(s)
- Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne and Research Professor, School of Nursing and Midwifery, Deakin University, Australia
| | - Stephen Mears
- Hunter New England Medical Library, New Lambton, Australia
| | - David Heslop
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Reece Hinchcliff
- University of Technology Sydney, Centre for Health Services Research, Ultimo, Australia
| | - Liz Hay
- Economics and Analyticss, Strategic Reform Branch, NSW Ministry of Health, North Sydney, Australia
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Bosch M, McKenzie JE, Ponsford JL, Turner S, Chau M, Tavender EJ, Knott JC, Gruen RL, Francis JJ, Brennan SE, Pearce A, O'Connor DA, Mortimer D, Grimshaw JM, Rosenfeld JV, Meares S, Smyth T, Michie S, Green SE. Evaluation of a targeted, theory-informed implementation intervention designed to increase uptake of emergency management recommendations regarding adult patients with mild traumatic brain injury: results of the NET cluster randomised trial. Implement Sci 2019; 14:4. [PMID: 30654826 PMCID: PMC6337860 DOI: 10.1186/s13012-018-0841-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 11/22/2018] [Indexed: 01/22/2023] Open
Abstract
Background Evidence-based guidelines for management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available; however, clinical practice remains inconsistent with these guidelines. A targeted, theory-informed implementation intervention (Neurotrauma Evidence Translation (NET) intervention) was designed to increase the uptake of three clinical practice recommendations regarding the management of patients who present to Australian EDs with mild head injuries. The intervention involved local stakeholder meetings, identification and training of nursing and medical local opinion leaders, train-the-trainer workshops and standardised education materials and interactive workshops delivered by the opinion leaders to others within their EDs during a 3 month period. This paper reports on the effects of this intervention. Methods EDs (clusters) were allocated to receive either access to a clinical practice guideline (control) or the implementation intervention, using minimisation, a method that allocates clusters to groups using an algorithm to minimise differences in predefined factors between the groups. We measured clinical practice outcomes at the patient level using chart audit. The primary outcome was appropriate screening for post-traumatic amnesia (PTA) using a validated tool until a perfect score was achieved (indicating absence of acute cognitive impairment) before the patient was discharged home. Secondary outcomes included appropriate CT scanning and the provision of written patient information upon discharge. Patient health outcomes (anxiety, primary outcome: Hospital Anxiety and Depression Scale) were also assessed using follow-up telephone interviews. Outcomes were assessed by independent auditors and interviewers, blinded to group allocation. Results Fourteen EDs were allocated to the intervention and 17 to the control condition; 1943 patients were included in the chart audit. At 2 months follow-up, patients attending intervention EDs (n = 893) compared with control EDs (n = 1050) were more likely to have been appropriately assessed for PTA (adjusted odds ratio (OR) 20.1, 95%CI 6.8 to 59.3; adjusted absolute risk difference (ARD) 14%, 95%CI 8 to 19). The odds of compliance with recommendations for CT scanning and provision of written patient discharge information were small (OR 1.2, 95%CI 0.8 to 1.6; ARD 3.2, 95%CI − 3.7 to 10 and OR 1.2, 95%CI 0.8 to 1.8; ARD 3.1, 95%CI − 3.0 to 9.3 respectively). A total of 343 patients at ten interventions and 14 control sites participated in follow-up interviews at 4.3 to 10.7 months post-ED presentation. The intervention had a small effect on anxiety levels (adjusted mean difference − 0.52, 95%CI − 1.34 to 0.30; scale 0–21, with higher scores indicating greater anxiety). Conclusions Our intervention was effective in improving the uptake of the PTA recommendation; however, it did not appreciably increase the uptake of the other two practice recommendations. Improved screening for PTA may be clinically important as it leads to appropriate periods of observation prior to safe discharge. The estimated intervention effect on anxiety was of limited clinical significance. We were not able to compare characteristics of EDs who declined trial participation with those of participating sites, which may limit the generalizability of the results. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12612001286831), date registered 12 December 2012. Electronic supplementary material The online version of this article (10.1186/s13012-018-0841-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marije Bosch
- Department of Surgery, Monash University, Melbourne, Australia. .,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia. .,Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands.
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia.,School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Simon Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marisa Chau
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Emma J Tavender
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Jonathan C Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L Gruen
- National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jill J Francis
- School of Health Sciences, City University of London, London, UK
| | - Sue E Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Pearce
- MedSTAR Emergency Medical Retrieval Service, Adelaide, Australia.,Royal Adelaide Hospital Emergency Department, Adelaide, Australia
| | - Denise A O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Australia
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Australia
| | - Susanne Meares
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Tracy Smyth
- Emergency Department, Westmead Hospital, Sydney, Australia
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sally E Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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Backman R, Foy R, Diggle PJ, Kneen R, Easton A, Defres S, McGill F, Michael BD, Solomon T. A pragmatic cluster randomised controlled trial of a tailored intervention to improve the initial management of suspected encephalitis. PLoS One 2018; 13:e0202257. [PMID: 30521521 PMCID: PMC6283633 DOI: 10.1371/journal.pone.0202257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 07/04/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether a tailored multifaceted implementation strategy improves the initial management of patients with suspected encephalitis. DESIGN Pragmatic two arm cluster randomised controlled trial. SETTING Hospitals within the United Kingdom. PARTICIPANTS Twenty-four hospitals nested within 12 postgraduate deaneries. Patients were identified retrospectively by searching discharge, microbiology, radiology and pharmacy records and included if they met clinical criteria or had a recorded suspicion of encephalitis. INTERVENTION An implementation strategy designed to overcome barriers to change, comprising local action planning, education and training, feedback on performance, a lumbar puncture pack and a range of optional components. OUTCOMES The primary outcome was the proportion of patients with suspected encephalitis undergoing diagnostic lumbar puncture within 12 hours of admission and starting aciclovir treatment within six hours. Secondary outcomes included the proportions of adults and children who had a lumbar puncture, who had appropriate cerebrospinal fluid investigations, and who had appropriate radiological imaging within 24 hours of admission. Data were collected from patient records for 12 months before and 12 months during the intervention period, and analysed blind to allocation. RESULTS 13 hospitals were randomised to intervention and 11 to control (no intervention), with 266 and 223 patients with suspected encephalitis identified respectively. There was no significant difference in primary outcome between intervention and control hospitals (13.5% and 14.8% respectively, p = 0.619; treatment effect -0.188, 95% confidence interval -0.927 to 0.552), but both had improved compared to pre-intervention (8.5%). CONCLUSION The improvement in both intervention and control arms may reflect overall progress in management of encephalitis through wider awareness and education. TRIAL REGISTRATION Controlled Trials: ISRCTN06886935.
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Affiliation(s)
- Ruth Backman
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter J. Diggle
- Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
- Department Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Rachel Kneen
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Ava Easton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, North Yorkshire, United Kingdom
| | - Sylviane Defres
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Fiona McGill
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Benedict Daniel Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Mortimer D, Bosch M, Mckenzie JE, Turner S, Chau M, Ponsford JL, Knott JC, Gruen RL, Green SE. Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments. Implement Sci 2018; 13:147. [PMID: 30518430 PMCID: PMC6280545 DOI: 10.1186/s13012-018-0834-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost. METHODS AND FINDINGS Study setting: The NET cluster randomised controlled trial [ACTRN12612001286831]. STUDY SAMPLE Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample). OUTCOME MEASURES Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D). METHODS Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample. RESULTS Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI - $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI - $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller's 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial. CONCLUSIONS While the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and-as delivered in the trial-is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612001286831 , date registered 12 December 2012.
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Affiliation(s)
- Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Australia.
| | - Marije Bosch
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Joanne E Mckenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Simon Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marisa Chau
- Department of Surgery, Monash University, Melbourne, Australia.,National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia.,School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jonathan C Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L Gruen
- National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Melbourne, Singapore
| | - Sally E Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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41
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Jeong D, Presseau J, ElChamaa R, Naumann DN, Mascaro C, Luconi F, Smith KM, Kitto S. Barriers and Facilitators to Self-Directed Learning in Continuing Professional Development for Physicians in Canada: A Scoping Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1245-1254. [PMID: 29642101 PMCID: PMC6092094 DOI: 10.1097/acm.0000000000002237] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
PURPOSE This scoping review explored the barriers and facilitators that influence engagement in and implementation of self-directed learning (SDL) in continuing professional development (CPD) for physicians in Canada. METHOD This review followed the six-stage scoping review framework of Arksey and O'Malley and of Daudt et al. In 2015, the authors searched eight online databases for English-language Canadian articles published January 2005-December 2015. To chart and analyze data from the 17 included studies, they employed a two-step analysis process composed of conventional content analysis followed by directed coding applying the Theoretical Domains Framework (TDF). RESULTS Conventional content analysis generated five categories of barriers and facilitators: individual, program, technological, environmental, and workplace/organizational. Directed coding guided by the TDF allowed analysis of barriers and facilitators to behavior change according to two key groups: physicians engaging in SDL, and SDL developers designing and implementing SDL programs. Of the 318 total barriers and facilitators coded, 290 (91.2%) were coded for physicians and 28 (8.8%) for SDL developers. The majority (209; 65.7%) were coded in four key TDF domains: environmental context and resources, social influences, beliefs about consequences, and behavioral regulation. CONCLUSIONS This scoping review identified five categories of barriers and facilitators in the literature and four key TDF domains where most factors related to behavior change of physicians and SDL developers regarding SDL programs in CPD were coded. There was a significant gap in the literature about factors that may contribute to SDL developers' capacity to design and implement SDL programs in CPD.
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Affiliation(s)
- Dahn Jeong
- D. Jeong is a research associate, Department of Innovation in Medical Education and Office of Continuing Professional Development, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- J. Presseau is a scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, and assistant professor, School of Epidemiology and Public Health and School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Rima ElChamaa
- R. ElChamaa is a research associate, Department of Innovation in Medical Education and Office of Continuing Professional Development, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Danielle N. Naumann
- D.N. Naumann is a research associate, Continuing Professional Development, and doctorate candidate, Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Colin Mascaro
- C. Mascaro is a fourth-year resident, Department of Physical Medicine and Rehabilitation, School of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Francesca Luconi
- F. Luconi is assistant dean, Continuing Professional Development, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Karen M. Smith
- K.M. Smith is associate dean, Continuing Professional Development, Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Simon Kitto
- S. Kitto is professor, Department of Innovation in Medical Education and the Faculty of Education, and director of research, Office of Continuing Professional Development, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; and assistant professor, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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42
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Isenor JE, Minard LV, Stewart SA, Curran JA, Deal H, Rodrigues G, Sketris IS. Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework. Res Social Adm Pharm 2018; 14:784-791. [DOI: 10.1016/j.sapharm.2017.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 10/02/2017] [Accepted: 10/08/2017] [Indexed: 10/18/2022]
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Bazarian JJ, Biberthaler P, Welch RD, Lewis LM, Barzo P, Bogner-Flatz V, Gunnar Brolinson P, Büki A, Chen JY, Christenson RH, Hack D, Huff JS, Johar S, Jordan JD, Leidel BA, Lindner T, Ludington E, Okonkwo DO, Ornato J, Peacock WF, Schmidt K, Tyndall JA, Vossough A, Jagoda AS. Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): a multicentre observational study. Lancet Neurol 2018; 17:782-789. [PMID: 30054151 DOI: 10.1016/s1474-4422(18)30231-x] [Citation(s) in RCA: 302] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/24/2018] [Accepted: 06/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND More than 50 million people worldwide sustain a traumatic brain injury (TBI) annually. Detection of intracranial injuries relies on head CT, which is overused and resource intensive. Blood-based brain biomarkers hold the potential to predict absence of intracranial injury and thus reduce unnecessary head CT scanning. We sought to validate a test combining ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), at predetermined cutoff values, to predict traumatic intracranial injuries on head CT scan acutely after TBI. METHODS This prospective, multicentre observational trial included adults (≥18 years) presenting to participating emergency departments with suspected, non-penetrating TBI and a Glasgow Coma Scale score of 9-15. Patients were eligible if they had undergone head CT as part of standard emergency care and blood collection within 12 h of injury. UCH-L1 and GFAP were measured in serum and analysed using prespecified cutoff values of 327 pg/mL and 22 pg/mL, respectively. UCH-L1 and GFAP assay results were combined into a single test result that was compared with head CT results. The primary study outcomes were the sensitivity and the negative predictive value (NPV) of the test result for the detection of traumatic intracranial injury on head CT. FINDINGS Between Dec 6, 2012, and March 20, 2014, 1977 patients were recruited, of whom 1959 had analysable data. 125 (6%) patients had CT-detected intracranial injuries and eight (<1%) had neurosurgically manageable injuries. 1288 (66%) patients had a positive UCH-L1 and GFAP test result and 671 (34%) had a negative test result. For detection of intracranial injury, the test had a sensitivity of 0·976 (95% CI 0·931-0·995) and an NPV of 0·996 (0·987-0·999). In three (<1%) of 1959 patients, the CT scan was positive when the test was negative. INTERPRETATION These results show the high sensitivity and NPV of the UCH-L1 and GFAP test. This supports its potential clinical role for ruling out the need for a CT scan among patients with TBI presenting at emergency departments in whom a head CT is felt to be clinically indicated. Future studies to determine the value added by this biomarker test to head CT clinical decision rules could be warranted. FUNDING Banyan Biomarkers and US Army Medical Research and Materiel Command.
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Affiliation(s)
- Jeffrey J Bazarian
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Peter Biberthaler
- Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Robert D Welch
- Department of Emergency Medicine, Wayne State University, Detroit Receiving Hospital, Detroit, MI, USA.
| | - Lawrence M Lewis
- Division of Emergency Medicine, Washington University, St Louis, MO, USA
| | - Pal Barzo
- University of Szeged, Szeged, Hungary
| | | | - P Gunnar Brolinson
- Carilion New River Valley Hospital, The Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Andras Büki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, János Szentágothai Research Center, Hungarian Brain Research Program, Medical School, University of Pecs, Pecs, Hungary
| | - James Y Chen
- Department of Radiology, VA San Diego Healthcare System/University of California, San Diego Health System, La Jolla, CA, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Dallas Hack
- US Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | | | - Sandeep Johar
- Neurosurgery, Orthopedics & Spine Specialist, Waterbury, CT, USA
| | - J Dedrick Jordan
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | | | - David O Okonkwo
- Department of Neurosurgical Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kara Schmidt
- US Army Medical Research and Materiel Command, Fort Detrick, MD, USA; US Army Medical Research and Material Command, Fort Detrick, MD, USA
| | - Joseph A Tyndall
- Department of Emergency Medicine, The University of Florida, Gainesville, FL, USA
| | - Arastoo Vossough
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Andy S Jagoda
- Department of Emergency Medicine, Mount Sinai Health System, New York, NY, USA
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Haskell L, Tavender EJ, Wilson C, O’Brien S, Babl FE, Borland ML, Cotterell L, Schuster T, Orsini F, Sheridan N, Johnson D, Oakley E, Dalziel SR. Implementing evidence-based practices in the care of infants with bronchiolitis in Australasian acute care settings: study protocol for a cluster randomised controlled study. BMC Pediatr 2018; 18:218. [PMID: 29980177 PMCID: PMC6035428 DOI: 10.1186/s12887-018-1187-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for admission to hospital for infants less than one year of age. Although management is well defined, there is substantial variation in practice, with infants receiving ineffective therapies or management. This study will test the effectiveness of tailored, theory informed knowledge translation (KT) interventions to decrease the use of five clinical therapies or management processes known to be of no benefit, compared to usual dissemination practices in infants with bronchiolitis. The primary objective is to establish whether the KT interventions are effective in increasing compliance to five evidence based recommendations in the first 24 h following presentation to hospital. The five recommendations are that infants do not receive; salbutamol, antibiotics, glucocorticoids, adrenaline, or a chest x-ray. METHODS/DESIGN This study is designed as a cluster randomised controlled trial. We will recruit 24 hospitals in Australia and New Zealand, stratified by country and provision of tertiary or secondary paediatric care. Hospitals will be randomised to either control or intervention groups. Control hospitals will receive a copy of the recent Australasian Bronchiolitis Guideline. Intervention hospitals will receive KT interventions informed by a qualitative analysis of factors influencing clinician care of infants with bronchiolitis. Key interventions include, local stakeholder meetings, identifying medical and nursing clinical leads in both emergency departments and paediatric inpatient areas who will attend a single education train-the-trainer day to then deliver standardised staff education with the training materials provided and coordinate audit and feedback reports locally over the study period. Data will be extracted retrospectively for three years prior to the study intervention year, and for seven months of the study intervention year bronchiolitis season following intervention delivery to determine compliance with the five evidence-based recommendations. Data will be collected to assess fidelity to the implementation strategies and to facilitate an economic evaluation. DISCUSSION This study will contribute to the body of knowledge to determine the effectiveness of tailored, theory informed interventions in acute care paediatric settings, with the aim of reducing the evidence to practice gaps in the care of infants with bronchiolitis. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616001567415 (retrospectively registered on 14 November 2016).
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Murdoch Childrens Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | | | - Sharon O’Brien
- Princess Margaret Hospital for Children, Perth, Australia
| | - Franz E. Babl
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Meredith L. Borland
- Princess Margaret Hospital for Children, Perth, Australia
- Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Liz Cotterell
- Armidale Rural Referral Hospital, Armidale, NSW Australia
- University of New England, Armidale, NSW Australia
| | - Tibor Schuster
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | - Francesca Orsini
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | | | - David Johnson
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ed Oakley
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - on behalf of PREDICT
- Paediatric Research in Emergency Departments International Collaborative, Melbourne, Australia
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McGann J, Manohar J, Hiscock H, O'Connor D, Hodgson J, Babl F, Sung V. Caring for crying babies: A mixed-methods study to understand factors influencing nurses' and doctors' management of infant colic. J Paediatr Child Health 2018; 54:653-660. [PMID: 29468777 DOI: 10.1111/jpc.13858] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 11/30/2017] [Indexed: 12/20/2022]
Abstract
AIM The aim of this study was to determine the barriers and enablers influencing the uptake of two recommendations from a tertiary paediatric hospital's clinical practice guidelines by maternal and child health nurses (MCHNs) and emergency department (ED) doctors: (i) explaining normal crying; and (ii) avoiding attributing crying to gastro-oesophageal reflux (GOR) and limiting anti-reflux medication use. METHODS The study was designed as 1-h focus group discussions, guided by the Theoretical Domains Framework, and a short questionnaire, with a purposive sample of MCHNs and ED doctors in Victoria, Australia in (March to September) 2015. Analyses were conducted by inductive content analysis to identify key barriers and enablers. RESULTS A total of 53 MCHNs and 25 ED doctors participated in 11 discussions. For explaining normal crying, key enablers were: adequate experience/competency, perceiving it was their role to explain and belief it prevented over-medicalisation. The main barriers were time restriction and beliefs about parents' perceptions. For MCHNs, key barriers to avoid attributing crying to GOR were: lack of knowledge and confusion around their role in diagnosing GOR. For ED doctors, key barriers to limiting anti-reflux medication were: parents requesting medication, concern about disrupting the parent-primary-care practitioner relationship and belief it was not their role to cease anti-reflux medication. CONCLUSIONS Overall, MCHN and ED doctors were proficient in describing normal crying. However, several barriers to best practice were identified, including time constraints and belief about consequences of intervening. These results will be used to develop effective interventions to address the identified barriers and enablers to optimise the management of infant colic.
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Affiliation(s)
- James McGann
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Jaqueline Manohar
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Harriet Hiscock
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jan Hodgson
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Franz Babl
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Valerie Sung
- Centre for Community Child Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Rowe BH, Eliyahu L, Lowes J, Gaudet LA, Beach J, Mrazik M, Cummings G, Voaklander D. A Prospective Evaluation of the Influence of an Electronic Clinical Practice Guidelines on Concussion Patients’ Future Activities and Outcomes. J Emerg Med 2018; 54:774-784. [DOI: 10.1016/j.jemermed.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/28/2018] [Accepted: 02/08/2018] [Indexed: 11/29/2022]
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Improving the implementation of nutrition guidelines in childcare centres improves child dietary intake: findings of a randomised trial of an implementation intervention. Public Health Nutr 2017; 21:607-617. [PMID: 29173218 DOI: 10.1017/s1368980017003366] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Evidence suggests that improvements to the childcare nutrition environment can have a positive impact on child dietary intake. The primary aim of the present study was to assess, relative to usual care, the effectiveness of a multi-strategy implementation intervention in improving childcare compliance with nutrition guidelines. As a secondary aim, the impact on child dietary intake was assessed. DESIGN Parallel-group, randomised controlled trial design. The 6-month intervention was designed to overcome barriers to implementation of the nutrition guidelines that had been identified by applying the theoretical domains framework. SETTING Hunter New England region, New South Wales, Australia. SUBJECTS Forty-five centre-based childcare services. RESULTS There were no differences between groups in the proportion of services providing food servings (per child) compliant with nutrition guideline recommendations for all five (5/5) food groups at follow-up (i.e. full compliance). Relative to control services, intervention services were more likely to be compliant with guidelines (OR; 95 % CI) in provision of fruit (10·84; 1·19, 551·20; P=0·0024), meat and meat alternatives (8·83; 1·55, -; P=0·023), dairy (8·41; 1·60, 63·62; P=0·006) and discretionary foods (17·83; 2·15, 853·73; P=0·002). Children in intervention services consumed greater servings (adjusted difference; 95 % CI) of fruit (0·41; 0·09, 0·73; P=0·014) and vegetables (0·70; 0·33, 1·08; P<0·001). CONCLUSIONS Findings indicate that service-level changes to menus in line with dietary guidelines can result in improvements to children's dietary intake. The study provides evidence to advance implementation research in the setting as a means of enhancing child public health nutrition.
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Brown AM, Twomey DM, Wong Shee A. Are patients with concussion getting optimal discharge advice at a regional emergency department? Aust J Rural Health 2017; 26:134-135. [PMID: 29105939 DOI: 10.1111/ajr.12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ashlee M Brown
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Dara M Twomey
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Anna Wong Shee
- Ballarat Health Services, Drummond Street North, Ballarat, Victoria, Australia
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Patrick SP, Gaudet LA, Krebs LD, Chambers T, Rowe BH. Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review. AEM EDUCATION AND TRAINING 2017; 1:346-356. [PMID: 30051054 PMCID: PMC6001600 DOI: 10.1002/aet2.10053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice. METHODS A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies. RESULTS Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations. CONCLUSIONS The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.
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Affiliation(s)
- Sean P. Patrick
- Faculty of MedicineUniversity of OttawaOttawaONCanada
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Lindsay A. Gaudet
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Lynette D. Krebs
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Thane Chambers
- J. W. Scott Health Sciences LibraryUniversity of AlbertaEdmontonABCanada
| | - Brian H. Rowe
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
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Backman R, Weber P, Turner AM, Lee M, Litchfield I. Assessing the extent of drug interactions among patients with multimorbidity in primary and secondary care in the West Midlands (UK): a study protocol for the Mixed Methods Multimorbidity Study (MiMMS). BMJ Open 2017; 7:e016713. [PMID: 28928183 PMCID: PMC5623557 DOI: 10.1136/bmjopen-2017-016713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION The numbers of patients with three or more chronic conditions (multimorbidity) are increasing, and will rise to 2.9 million by 2018 in the UK alone. Currently in the UK, conditions are mainly managed using over 250 sets of single-condition guidance, which has the potential to generate conflicting recommendations for lifestyle and concurrent medication for individual patients with more than one condition. To address some of these issues, we are developing a new computer-based tool to help manage these patients more effectively. For this tool to be applicable and relevant to current practice, we must first better understand how existing patients with multimorbidity are being managed, particularly relating to concerns over prescribing and potential polypharmacy. METHODS AND ANALYSIS Up to four secondary care centres, two community pharmacies and between four and eight primary care centres in the West Midlands will be recruited. Interviewees will be purposively sampled from these sites, up to a maximum of 30. In this mixed methods study, we will perform a dual framework analysis on the qualitative data; the first analysis will use the Theoretical Domains Framework to assess barriers and enablers for healthcare professionals around the management of multimorbid patients; the second analysis will use Normalisation Process Theory to understand how interventions are currently being successfully implemented in both settings. We will also extract quantitative anonymised patient data from primary care to determine the extent of polypharmacy currently present for patients with multimorbidity in the West Midlands. DISCUSSION We aim to combine these data so that we can build a useful, fully implementable tool which addresses the barriers most amenable to change within both primary and secondary care contexts. ETHICS AND DISSEMINATION Favourable ethical approval has been granted by The University of Birmingham Research Ethics Committee (ERN_16-0074) on 17 May 2016. Our work will be disseminated through peer-reviewed literature, trade journals and conferences. We will also use the dedicated web page hosted by the University to serve as a central point of contact and as a repository of our findings. We aim to produce a minimum of three articles from this work to contribute to the international scientific literature. PROTOCOL REGISTRATION NUMBER NIHR Clinical Research Network Portfolio Registration CPMS ID 30613.
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Affiliation(s)
- Ruth Backman
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Philip Weber
- School of Computer Science, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Mark Lee
- School of Computer Science, University of Birmingham, Birmingham, UK
| | - Ian Litchfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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