Barriers to and facilitators of the development and utilization of context appropriate evidence based clinical algorithms to optimize clinical care and patient outcomes in the Tikur Anbessa emergency department: a multi-component qualitative study

Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review

OBJECTIVE

A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers' use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers.

DESIGN

Scoping review.

DATA SOURCES

The literature search was conducted using PubMed in January 2021.

ELIGIBILITY CRITERIA

We identified empirical studies, published between 2011-2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC.

DATA EXTRACTION AND SYNTHESIS

Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis.

RESULTS

The review identified five types of interacting factors that influence healthcare providers' use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system.

CONCLUSION

The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts.

Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis

BACKGROUND

Despite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context.

METHODS

We employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student's t-test to compare group means for percentage of scenarios with correct diagnosis.

RESULTS

A total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98-1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88-1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges.

CONCLUSION

We found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation.

TRIAL REGISTRATION

Open Science Framework osf.io/ju4ga . Registered June 28, 2017.

Analysis of Influencing Factors of Acute Medication Poisoning in Adults in Emergency Department of Our Hospital from 2016 to 2019 and Observation of Curative Effect of Optimizing Emergency Procedures

Objective. This study analyzed the influencing factors of acute medication poisoning in adults in the emergency department of our hospital from January 2016 to December 2019 and observed the curative effect of optimizing emergency procedures on adult acute medication poisoning. Our results showed that, among all acute drug poisoning patients, the most common poisoning drug was sleeping pills (24.22%), followed by painkillers (20.31%) and antipsychotics (16.41%). Education level, drug category, drug source, drug dosage, unknown drug composition, and medication side effect were all influencing factors of acute drug poisoning. High school education level or below, self-purchasing medicine, medication overdose, unknown drug composition, and medication side effect were the risk factors of acute medication poisoning. In addition, after the nursing management of optimizing emergency procedures for this type of patients, the rescue time, observation time, and hospital stay of the patients had been shortened, the incidence of complications was low, the rescue success rate was high, and the clinical application effect was good.

Implementation of the clinical practice guideline for individuals with amputations in Colombia: a qualitative study on perceived barriers and facilitators

Background

The issue of lower extremity amputation has been in the Colombian political agenda for its relationship with the armed conflict and antipersonnel mines. In 2015 the Colombian Ministry of Health published a national clinical practice guideline (CPG) for amputee patients. However, there is a need to design implementation strategies that target end-users and the context in which the CPG will be used. This study aims to identify users’ perceptions about the barriers and facilitators for implementing the guideline for the care of amputee patients in a middle-income country such as Colombia.

Methods

Semi-structured interviews were conducted with 38 users, including patients, health workers, and administrative staff of institutions of the health system in Colombia. Individuals were purposively selected to ensure different perspectives, allowing a balance of individual positions.

Results

According to participants’ perceptions, barriers to implementation are classified as individual barriers (characteristics of the amputee patient and professionals), health system barriers (resource availability, timely care, information systems, service costs, and regulatory changes), and barriers related to clinical practice guidelines (utility, methodological rigour, implementation flexibility, and characteristics of the group developing the guidelines).

Conclusions

Our study advances knowledge on the perceived individual and health system barriers and facilitators for the implementation of the CPG for amputee patients in Colombia. Importantly, the governance, financial, and service delivery arrangements of the Colombian health system are determining factors in implementing CPGs. For example, the financial arrangements between the insurance companies and the health care provider institutions were identified as barriers for the implementation of recommendations related to the continuity and opportunity of care of patients with amputations. The design of implementation strategies that successfully address the individual behaviours and the contextual health systems arrangements may significantly impact the health care process for amputee patients in Colombia.

Nutrition services offered to pregnant women attending antenatal clinics in Dar es Salaam, Tanzania: A qualitative study

OBJECTIVES

To provide an overview of the qualifications of nurses working in antenatal clinics, and to identify current nutrition services and information provided to pregnant women. To explore barriers and enablers to the provision of nutrition services by nurses to pregnant women attending antenatal clinics mapped against the Theoretical Domains Framework.

DESIGN AND SETTING

Cross-sectional qualitative study, conducted in three municipal hospitals (Temeke, Mwananyamala and Ilala) in Dar es Salaam, Tanzania.

PARTICIPANTS

Fourteen nurses currently providing health services to pregnant women, with at least two months' work experience within in the selected facility were purposively selected.

METHOD

In-depth interviews were carried out with the participants by three trained research assistants using guides prepared in Swahili. Transcripts were translated into English and imported to NVivo 12 software. Data was analysed using qualitative content analysis principles.

RESULTS

Five nutrition services commonly provided to pregnant women at antenatal clinics were nutrition education, iron and folic acid supplementation, weight measurements, dietary assessment and haemoglobin level monitoring. Domains included knowledge, skills, beliefs about capabilities, in addition to memory, attention and decision processes, and the environmental context and resources domains had both barriers and enablers identified by participants. The three remaining domains of the social/professional role and identity, optimism, and beliefs about consequences had only enablers reported.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Nurses deliver nutrition care to pregnant women during routine antenatal clinic visits. However, the information delivered to pregnant women varied among nurses, and a number of barriers and enablers to provision of nutrition care to pregnant women were identified. This data can inform future improvement to strategies for implementing nutrition services to pregnant women attending antenatal clinics. In-service training to nurses working with pregnant women and availability of tailored nutrition education materials, such as a food guide in these health facilities could improve nutrition care during this important period.