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Kim HM, Jo HS, Kim EJ, Na JM, Park HK, Han JY, Kim KH, Choi I, Song MK. The Effect of Repetitive Transcranial Magnetic Stimulation on Cognition in Diffuse Axonal Injury in a Rat Model. Neurol Int 2024; 16:689-700. [PMID: 39051213 PMCID: PMC11270180 DOI: 10.3390/neurolint16040052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/27/2024] Open
Abstract
Diffuse axonal injury (DAI) following sudden acceleration and deceleration can lead to cognitive function decline. Various treatments have been proposed. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive stimulation technique, is a potential treatment for enhancing neuroplasticity in cases of brain injury. The therapeutic efficacy of rTMS on cognitive function remains unconfirmed. This study investigated the effects of rTMS and the underlying molecular biomechanisms using a rat model of DAI. Sprague-Dawley rats (n = 18) were randomly divided into two groups: one receiving rTMS after DAI and the other without brain stimulation. All rats were subjected to sudden acceleration and deceleration using a DAI modeling machine to induce damage. MRI was performed to confirm the DAI lesion. The experimental group received rTMS at a frequency of 1 Hz over the frontal cortex for 10 min daily for five days. To assess spatial memory, we conducted the Morris water maze (MWM) test one day post-brain damage and one day after the five-day intervention. A video tracking system recorded the escape latency. After post-MWM tests, all rats were euthanized, and their brain tissues, particularly from the hippocampus, were collected for immunohistochemistry and western blot analyses. The escape latency showed no difference on the MWM test after DAI, but a significant difference was observed after rTMS between the two groups. Immunohistochemistry and western blot analyses indicated increased expression of BDNF, VEGF, and MAP2 in the hippocampal brain tissue of the DAI-T group. In conclusion, rTMS improved cognitive function in the DAI rat model. The increased expression of BDNF, VEGF, and MAP2 in the DAI-T group supports the potential use of rTMS in treating cognitive impairments associated with DAI.
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Affiliation(s)
| | | | | | | | | | | | | | - Insung Choi
- Department of Physical & Rehabilitation Medicine, Chonnam National University Medical School & Hospital, Gwangju 61469, Republic of Korea; (H.-M.K.); (H.-S.J.); (E.-J.K.); (J.-M.N.); (H.-K.P.); white-- (J.-Y.H.); (K.-H.K.)
| | - Min-Keun Song
- Department of Physical & Rehabilitation Medicine, Chonnam National University Medical School & Hospital, Gwangju 61469, Republic of Korea; (H.-M.K.); (H.-S.J.); (E.-J.K.); (J.-M.N.); (H.-K.P.); white-- (J.-Y.H.); (K.-H.K.)
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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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Memmini AK, Kinnett-Hopkins DL, Hasson RE, Rifat SF, Broglio SP. Considerations for Implementing the Post-Concussion Collegiate Return-to-Learn Protocol in the National Collegiate Athletic Association Power 5 Conferences. J Head Trauma Rehabil 2023; 38:336-347. [PMID: 36854099 DOI: 10.1097/htr.0000000000000862] [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: 03/02/2023]
Abstract
OBJECTIVE Although concussions affect millions of young adults annually, researchers have yet to assess factors that may affect future implementation of post-concussion academic supports within higher education. Therefore, we sought to evaluate preimplementation outcomes of the acceptability, feasibility, appropriateness, and readiness for change of the Post-Concussion Collegiate Return-to-Learn (RTL) Protocol among university stakeholders. SETTING An online survey. PARTICIPANTS A convenience sample ( N = 49; 63.3% female) of athletic trainers (ATs; n = 25, age = 30.1 ± 7.6 years) and university faculty/staff ( n = 24, age = 38.3 ± 9.9 years) across the National Collegiate Athletic Association (NCAA) Power 5 Conferences from January to February 2022. DESIGN A cross-sectional study. MAIN MEASURES To compare preimplementation outcome measures using the Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM), Intervention Appropriateness Measure (IAM), and Organizational Readiness for Implementing Change (ORIC) regarding the RTL protocol between ATs and university faculty/staff. Additional outcomes included internal and external barriers to implementing at their respective institutions. Statistical analyses were conducted using Mann-Whitney U tests, with effect sizes estimated using eta-squared coefficient (η 2 ). RESULTS Quantitative analyses yielded no statistically significant group differences ( P s > .05) across the AIM, FIM, and IAM outcomes, indicating both groups perceived the protocol to be acceptable, feasible, and appropriate. Moreover, ATs reported higher agreement regarding motivation, desire, willingness to do "whatever it takes," commitment, and determination to implement the novel protocol than faculty/staff. Further, ATs reported higher agreement regarding their institution's confidence to keep track of its progress, support adjustment, maintain momentum, manage institutional politics, coordinate tasks, encourage investment, and handle the challenges of future implementation of the RTL protocol. CONCLUSIONS Preliminary findings suggest ATs and university faculty/staff across the NCAA Power 5 Conferences may perceive the RTL protocol to be acceptable, feasible, and appropriate for future use; however, noteworthy internal and external barriers may influence its uptake. Future research should utilize implementation frameworks to support the protocol's adoption and reach.
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Affiliation(s)
- Allyssa K Memmini
- Department of Health, Exercise and Sports Sciences, University of New Mexico, Albuquerque, New Mexico (Dr Memmini); Concussion Center, University of Michigan, Ann Arbor (Drs Memmini, Kinnett-Hopkins, Hasson, and Broglio); and School of Kinesiology, University of Michigan, Ann Arbor, and University of Michigan Athletics, Michigan Medicine, Ann Arbor (Dr Rifat)
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Curtis K, Dinh MM, Shetty A, Kourouche S, Fry M, Considine J, Li L, Lung T, Shaw T, Lam MK, Murphy M, Alkhouri H, Aggar C, Russell SB, Seimon RV, Hughes JA, Varndell W, Shaban RZ. The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial. Implement Sci Commun 2023; 4:70. [PMID: 37340486 DOI: 10.1186/s43058-023-00452-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/04/2023] [Indexed: 06/22/2023] Open
Abstract
INTRODUCTION Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes. METHODS AND ANALYSIS This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys. ETHICS AND DISSEMINATION Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022. TRIAL REGISTRATION Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.
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Affiliation(s)
- Kate Curtis
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, NSW, Australia.
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia.
| | - Michael M Dinh
- New South Wales Institute of Trauma and Injury Management, Chatswood, Australia
- Sydney Medical School, The University of Sydney, Camperdown, Australia
- RPA Green Light Institute for Emergency Care, Sydney Local Health District, Camperdown, Australia
| | - Amith Shetty
- System Sustainability and Performance, NSW Ministry of Health, St Leonards, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Sarah Kourouche
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, NSW, Australia
| | - Margaret Fry
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, NSW, Australia
- Sydney Faculty of Health, University of Technology, Ultimo, NSW, Australia
- Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, VIC, Australia
| | - Ling Li
- Macquarie University, Sydney, Australia
| | - Thomas Lung
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Timothy Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Mary K Lam
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Margaret Murphy
- Western Sydney Local Health District, North Parramatta, NSW, 2145, Australia
| | - Hatem Alkhouri
- Agency for Clinical Innovation, NSW Emergency Care Institute, St Leonards, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Christina Aggar
- Nothern NSW Local Health District, Southern Cross University, Lismore, Australia
| | | | - Radhika V Seimon
- RPA Green Light Institute for Emergency Care, Sydney Local Health District, Camperdown, Australia
| | - James A Hughes
- School of Nursing, Centre for Healthcare Transformation, Brisbane, QUT, Australia
| | - Wayne Varndell
- Prince of Wales Hospital Emergency Department, Randwick, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, Australia
- College of Emergency Nursing Australasia (CENA), Hobart, Australia
| | - Ramon Z Shaban
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, NSW, Australia
- Faculty of Medicine and Health, Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, 2006, Australia
- Communicable Diseases Branch, Public Health Unit, Centre for Population Health, Western Sydney Local Health District, North Parramatta, NSW, 2141, Australia
- New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Westmead, NSW, 2145, Australia
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Barnden R, Snowdon DA, Lannin NA, Lynch E, Srikanth V, Andrew NE. Prospective application of theoretical implementation frameworks to improve health care in hospitals - a systematic review. BMC Health Serv Res 2023; 23:607. [PMID: 37296453 DOI: 10.1186/s12913-023-09609-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. METHOD We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. RESULTS Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. CONCLUSIONS Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. TRIAL REGISTRATION CRD42019119429.
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Affiliation(s)
- Rebecca Barnden
- Academic Unit, Peninsula Health, Frankston, VIC, Australia.
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, VIC, Australia.
- National Centre for Healthy Ageing, Melbourne, VIC, Australia.
| | - David A Snowdon
- Academic Unit, Peninsula Health, Frankston, VIC, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, VIC, Australia
- National Centre for Healthy Ageing, Melbourne, VIC, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | - Elizabeth Lynch
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Velandai Srikanth
- Academic Unit, Peninsula Health, Frankston, VIC, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, VIC, Australia
- National Centre for Healthy Ageing, Melbourne, VIC, Australia
| | - Nadine E Andrew
- Academic Unit, Peninsula Health, Frankston, VIC, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, VIC, Australia
- National Centre for Healthy Ageing, Melbourne, VIC, Australia
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Cross AJ, Haines TP, Ooi CE, La Caze A, Karavesovska S, Lee EJ, Siu S, Sareen S, Jones C, Steeper M, Bell JS. Roles and effectiveness of knowledge brokers for translating clinical practice guidelines in health-related settings: a systematic review. BMJ Qual Saf 2023; 32:286-295. [PMID: 36746617 DOI: 10.1136/bmjqs-2022-015595] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Poor translation of clinical practice guidelines (CPGs) into clinical practice is a barrier to the provision of consistent and high-quality evidence-based care. The objective was to systematically review the roles and effectiveness of knowledge brokers (KBs) for translating CPGs in health-related settings. METHODS MEDLINE, Embase, PsycINFO and CINAHL Plus were searched from 2014 to June 2022. Randomised controlled trials (RCTs), controlled and uncontrolled preintervention and postintervention studies involving KBs, either alone or as part of a multicomponent intervention, that reported quantitative postintervention changes in guideline implementation in a healthcare setting were included. A KB was defined as an intermediary who facilitated knowledge translation by acting in at least two of the following core roles: knowledge manager, linkage agent or capacity builder. Specific activities undertaken by KBs were deductively coded to the three core roles, then common activities were inductively grouped. Screening, data extraction, quality assessment and coding were performed independently by two authors. RESULTS 16 studies comprising 6 RCTs, 8 uncontrolled precomparisons-postcomparisons, 1 controlled precomparison-postcomparison and 1 interrupted time series were included. 14 studies (88%) were conducted in hospital settings. Knowledge manager roles included creating and distributing guideline material. Linkage agent roles involved engaging with internal and external stakeholders. Capacity builder roles involved audit and feedback and educating staff. KBs improved guideline adherence in 10 studies (63%), had mixed impact in 2 studies (13%) and no impact in 4 studies (25%). Half of the RCTs showed KBs had no impact on guideline adherence. KBs acted as knowledge managers in 15 (94%) studies, linkage agents in 11 (69%) studies and capacity builders in all studies. CONCLUSION Knowledge manager and capacity builder roles were more frequently studied than linkage agent roles. KBs had mixed impact on translating CPGs into practice. Further RCTs, including those in non-hospital settings, are required. PROSPERO REGISTRATION NUMBER CRD42022340365.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Choon Ean Ooi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Adam La Caze
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Sara Karavesovska
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Eu Jin Lee
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Samuel Siu
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Sagar Sareen
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Carlos Jones
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - Michelle Steeper
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
| | - John Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville Campus, Parkville, Victoria, Australia
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Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17:50. [PMID: 35870974 PMCID: PMC9308215 DOI: 10.1186/s13012-022-01223-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics. Results We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions. Conclusions Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact. Trial registration The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01223-6.
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Radisic G, de la Perrelle L, Laver K. Methods of Capturing Process Outcomes in Quality Improvement Trials: A Systematic Review. J Healthc Qual 2022; 44:131-151. [PMID: 35119423 DOI: 10.1097/jhq.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Healthcare quality can be measured by studying structure, processes, and outcomes. This study examines how trialists capture process outcomes in implementation trials to provide guidance for researchers and health professionals. Electronic databases were searched, and two researchers performed the title, abstract, and full-text selection. Only implementation studies involving nonpharmacological approaches were included. Data were extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Study quality was independently assessed by two reviewers. Of the 3,186 articles screened, 24 studies matched our inclusion criteria. Most studies were cluster randomized control trials, followed by interrupted time series studies and stepped wedge studies. The population in the studies was diverse and settings included hospitals, community centers, residential aged care facilities, and primary care. The reporting of process measures across the included studies varied, and there was limited information about the mechanisms of data collection procedures. Nineteen studies extracted information about processes from electronic medical records, patient records, or chart reviews. The remaining five studies used staff surveys. Challenges remain in the practical aspect of data collection for measuring process outcomes, particularly outside of hospital settings or where processes are hard to capture in patient records.
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Dhandapani TPM, Garg I, Tara A, Patel JN, Dominic JL, Yeon J, Memon MS, Gergal Gopalkrishna Rao SR, Bugazia S, Khan S. Role of the Treatment of Post-Concussion Syndrome in Preventing Long-Term Sequela Like Depression: A Systematic Review of the Randomized Controlled Trials. Cureus 2021; 13:e18212. [PMID: 34722025 PMCID: PMC8544623 DOI: 10.7759/cureus.18212] [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: 07/27/2021] [Accepted: 09/23/2021] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury of any severity can result in post-concussion syndrome (PCS). Although the post-concussive symptoms are complex, there is an emerging scientific consensus regarding the initiation of the treatment for these symptoms to improve quality of life and prevent long-term effects. The objective of this systematic review is to assess the comprehensive interventions used for the PCS and it aims to appraise if these interventions could prevent the development of depression as a complication. This research has used randomized controlled trials (RCTs) that evaluate the treatment of PCS and its effect on long-term complications like depression. We searched PubMed/MEDLINE, PubMed Central, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE from January 1, 2016 to May 31, 2021 for our literature search. A quality check was conducted on the identified studies using the Cochrane risk of bias quality assessment tool (modified Cochrane RoB 2). In total, we included 11 RCTs and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for the reporting of this systematic review. Most of the studies reinforced early initiation of the treatment by providing education to the patients and conducting their risk assessment. Strong evidence for the multidisciplinary treatment consisting of cognitive-behavioral therapy, psychoeducation, and physiotherapy is emphasized by some studies. More studies with a longer follow-up period are required to assess the effectiveness of intervention more accurately on depression. Regardless, this study will discuss guidelines and provide direction to physicians. It will help in developing future guidelines by addressing the clinical gaps in the implementation of these guidelines.
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Affiliation(s)
| | - Ishan Garg
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Anjli Tara
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jaimin N Patel
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jerry Lorren Dominic
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jimin Yeon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Marrium S Memon
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Seif Bugazia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Abstract
OBJECTIVE Clinical practice guidelines (CPGs) synthesize research evidence for health professionals and improve consistency of clinical care. However, it is unclear if concussion clinicians use them in their practice. We aimed to describe which CPGs New Zealand clinicians used and facilitators and barriers to uptake of these resources. MATERIALS AND METHODS We used snowballing recruitment methods to survey New Zealand concussion clinicians. Descriptive statistics and qualitative description were used to evaluate survey responses. RESULTS Ninety-six clinicians took part in the survey. A majority (70%) indicated they were aware of and had used at least one concussion CPG. Facilitators and barriers to using CPGs related to clinician experience, nature of the CPG, the work context, characteristics of clients and whether strategies were provided to encourage their use. CONCLUSIONS Participants viewed concussion CPGs as helpful tools for informing clinical practice. That less experienced clinicians were less likely to use concussion CPGs than more experienced clinicians suggests there is an opportunity to develop strategies to improve the uptake of CPGs among newer clinicians. This and other areas of further research include how well CPGs capture relevant cultural factors and the role of case complexity in clinicians' willingness to use concussion CPGs.
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Affiliation(s)
- Sarah Derbyshire
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand
| | - Virginia Maskill
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand
| | - Deborah L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
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11
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Evans V. Caring for Traumatic Brain Injury Patients: Australian Nursing Perspectives. Crit Care Nurs Clin North Am 2021; 33:21-36. [PMID: 33526196 DOI: 10.1016/j.cnc.2020.10.002] [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] [Indexed: 11/16/2022]
Abstract
Each year, millions of people suffer traumatic brain injury (TBI). It is not inherent to any country or group of people. It occurs as a result of falls, combat situations, sports injury, schoolyard playgrounds, and car accidents. It does not discriminate with age or status. Cost implications for health care settings and individuals are substantial. Management requires prompt neurologic assessment by a highly specialized multidisciplinary team of neuroscience practitioners. It is important to understand normal brain anatomy and physiology to identify what is unusual or abnormal. Keen observational skills and constant questioning aid in early detection of neurologic deterioration.
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Affiliation(s)
- Vicki Evans
- World Federation of Neuroscience Nurses; Neuroscience, Royal North Shore Hospital, Pacific Highway, St. Leonard's, Sydney, New South Wales 2065, Australia.
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12
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Haskell L, Tavender EJ, Wilson CL, O'Brien S, Babl FE, Borland ML, Cotterell E, Sheridan N, Oakley E, Dalziel SR. Development of targeted, theory-informed interventions to improve bronchiolitis management. BMC Health Serv Res 2021; 21:769. [PMID: 34344383 PMCID: PMC8335893 DOI: 10.1186/s12913-021-06724-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. METHODS A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. RESULTS Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. CONCLUSION A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Curtin University, Perth, Western Australia, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Austalia, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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13
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Zatzick D, Moloney K, Palinkas L, Thomas P, Anderson K, Whiteside L, Nehra D, Bulger E. Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example. Med Care 2021; 59:S379-S386. [PMID: 34228020 PMCID: PMC8263139 DOI: 10.1097/mlr.0000000000001564] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice. OBJECTIVES This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed. CONCLUSIONS Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.
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Affiliation(s)
- Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Lawrence Palinkas
- Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, CA
| | - Peter Thomas
- Powers Pyles Sutter and Verville PC, Washington, DC
| | - Kristina Anderson
- The Koshka Foundation and Department of Psychiatry and Behavioral Sciences
| | | | - Deepika Nehra
- Surgery, University of Washington School of Medicine, Seattle, WA
| | - Eileen Bulger
- Surgery, University of Washington School of Medicine, Seattle, WA
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14
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Haskell L, Tavender EJ, Wilson CL, O’Brien S, Babl FE, Borland ML, Cotterell E, Schembri R, Orsini F, Sheridan N, Johnson DW, Oakley E, Dalziel SR. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:797-806. [PMID: 33843971 PMCID: PMC8042564 DOI: 10.1001/jamapediatrics.2021.0295] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care. OBJECTIVE To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020. INTERVENTIONS Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback. MAIN OUTCOMES AND MEASURES The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions. RESULTS A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001). CONCLUSIONS AND RELEVANCE Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
| | - Emma J. Tavender
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Catherine L. Wilson
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Sharon O’Brien
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Curtin University, Bentley, Western Australia, Australia
| | - Franz E. Babl
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Pediatric Emergency Medicine, University of Melbourne, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Faculty of Health and Medical Sciences (Pediatrics and Emergency Medicine), The University of Western Australia, Western Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, New South Wales, Australia,School of Rural Medicine, University of New England, New South Wales, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Nicolette Sheridan
- Center for Nursing and Health Research, Massey University, Auckland, Auckland, New Zealand
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ed Oakley
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia,University of Melbourne, Victoria, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand,Departments of Surgery and Pediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
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15
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Kourouche S, Curtis K, Munroe B, Asha SE, Carey I, Considine J, Fry M, Lyons J, Middleton S, Mitchell R, Shaban RZ, Unsworth A, Buckley T. Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation. Aust Crit Care 2021; 35:113-122. [PMID: 34144864 DOI: 10.1016/j.aucc.2021.04.003] [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: 02/07/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. OBJECTIVE The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. METHODS This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. RESULTS/FINDINGS Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). CONCLUSIONS High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.
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Affiliation(s)
- Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia; Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia.
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia.
| | - Stephen Edward Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia; St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Ian Carey
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Experience - Eastern Health Partnership, Box Hill, VIC, Australia.
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney Faculty of Health, NSW, Australia; Northern Sydney Local Health District, NSW, Australia.
| | - Jack Lyons
- School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, NSW Australia.
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113.
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW 2006, Australia; Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia.
| | - Annalise Unsworth
- South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, NSW 2006, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
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16
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Hlungwane EZ, Ten Ham-Baloyi W, Jordan P, Oamen BR. Nurses' Knowledge on Sepsis Related to Mechanical Ventilation: An Intervention Study. J Nurs Res 2021; 29:e158. [PMID: 33958552 DOI: 10.1097/jnr.0000000000000434] [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: 10/21/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of mortality and morbidity worldwide. South African adult public critical care units experience incidences of sepsis on an ongoing basis. Nurses caring for mechanically ventilated adult patients in intensive care units (ICUs) need to base their nursing care on "surviving sepsis campaign" (SSC) guidelines to properly manage sepsis. Adequate knowledge on sepsis guidelines remains crucially indicated for nurses as they endeavor to maintain asepsis in critically ill patients. PURPOSE This study was conducted to assess the effect of an educational intervention on nurses' knowledge and practices of sepsis in mechanically ventilated adult patients in public ICUs. METHODS An intervention study, with quasi-intervention two-group, pretest-posttest design, was used to collect data using a self-administered, structured, pretest and posttest questionnaire designed to measure nurses' knowledge and practices on sepsis related to mechanical ventilation. The study was conducted between June and October 2018. An educational intervention was developed and validated. Five purposively selected public ICUs in the Eastern Cape, South Africa, were selected and assigned to three groups: Intervention Group 1 (ICUs 1 and 2), which received the full intervention (containing a 20-minute PowerPoint presentation, printed materials based on sections of the SSC guidelines, and monitoring visits bimonthly for 3 months); Intervention Group 2 (ICUs 3 and 4; receiving the same as Intervention Group 1 but with no monitoring visits); and the control group (ICU 5; receiving no intervention). RESULTS One hundred seventeen nurses completed the questionnaires at pretest, and 94 completed the questionnaires at posttest, producing a response rate of 79% and 80%, respectively. The results revealed a significant knowledge score increase between pretest and posttest for both Intervention Group 2 (53.28 ± 14.39 and 62.18 ± 13.60, respectively; p = .004) and the control group (56.72 ± 13.72 and 70.05 ± 12.40, respectively; p = .001). Similarly, a recommended practice score increase was shown for Intervention Group 2 (58.8 ± 9.63 and 62.80 ± 9.52, respectively), and a significant increase was shown for the control group (56.72 ± 7.54 and 63.29 ± 5.89, respectively; p = .002). Intervention Group 1 showed a detectable but not significant decline in knowledge (57.72 ± 13.99 and 54.61 ± 12.15, respectively) and recommended practice (61.22 ± 8.66 and 60.33 ± 7.83, respectively) scores. CONCLUSIONS The availability of SSC guidelines was found to have increased knowledge on sepsis related to mechanical ventilation, although including monitoring visits as part of the educational intervention was not found to have a positive effect on increasing knowledge and practices. Further studies are required to explore factors contributing to improving knowledge and practices on sepsis related to mechanical ventilation and the effect that various educational interventions have in this context.
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Affiliation(s)
| | - Wilma Ten Ham-Baloyi
- PhD, RN, Research Associate, Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa
| | - Portia Jordan
- PhD, RN, Professor, Faculty of Medicine and Health Sciences, Department of Nursing and Midwifery, Stellenbosch University, South Africa
| | - Benedict Raphael Oamen
- BSN, RN, Master Student, Department of Nursing Science, Nelson Mandela University, Port Elizabeth, South Africa
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17
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18
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Westafer LM, Kunz A, Bugajska P, Hughes A, Mazor KM, Schoenfeld EM, Stefan MS, Lindenauer PK. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. Acad Emerg Med 2020; 27:447-456. [PMID: 32220127 PMCID: PMC7418048 DOI: 10.1111/acem.13908] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE. METHODS We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. RESULTS We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. CONCLUSIONS This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.
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Affiliation(s)
- Lauren M Westafer
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Ashley Kunz
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | | | - Amber Hughes
- University of Massachusetts Amherst, Amherst, MA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA
- and the, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Elizabeth M Schoenfeld
- From the, Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Mihaela S Stefan
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Peter K Lindenauer
- the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
- and the, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
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19
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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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Pozzato I, Meares S, Kifley A, Craig A, Gillett M, Vu KV, Liang A, Cameron I, Gopinath B. Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study. BMJ Open 2020; 10:e034494. [PMID: 32019818 PMCID: PMC7045153 DOI: 10.1136/bmjopen-2019-034494] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We also aimed to describe challenges in mTBI case identification and its acute hospital management. DESIGN AND SETTING A retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015-February 2016). PARTICIPANTS Adults aged 18-65 years consecutively presenting to an ED. PRIMARY OUTCOME MEASURES Proportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, 'mTBI', 'concussion'). RESULTS Of 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a 'mTBI diagnosis' clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%). CONCLUSIONS mTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.
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Affiliation(s)
- Ilaria Pozzato
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Susanne Meares
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Annette Kifley
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Ashley Craig
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Kim Van Vu
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Anthony Liang
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Ian Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | - Bamini Gopinath
- John Walsh Centre for Rehabilitation Research, Kolling Institute, University of Sydney, St Leonards, New South Wales, 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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