Barriers and facilitators towards implementing the Sepsis Six care bundle (BLISS-1): a mixed methods investigation using the theoretical domains framework

Implementing the information system for older adult patients post-discharge self-management: a qualitative study

BACKGROUND

Discharging older adult patients from the hospital poses risks due to their vulnerable conditions, complex instructions and limited health literacy. Insufficient information about medication side effects adds to patient concerns. To address this, a post-discharge information summary system was developed. While it has shown positive impacts, concerns exist regarding implementation fidelity.

OBJECTIVE

This study employed a theory-driven approach to understand health providers' perspectives on effective implementation.

METHOD

Individual semi-structured interviews were conducted via telephone with nurses, doctors and pharmacists from local public hospitals. All interviews were audio-recorded and transcribed verbatim. Theoretical Domains Framework (TDF) was applied for direct content analysis. Belief statements were generated by thematic synthesis under each of the TDF domains.

RESULTS

A total of 98 participants were interviewed. Out of the 49 belief statements covering eight TDF domains, 19 were determined to be highly relevant to the implementation of the post-discharge information summary system. These TDF domains include knowledge, skills, social/professional role and identity, beliefs about consequences, intentions, memory, attention and decision processes, environmental context and resources and social influences.

CONCLUSION

Our study contributes to the understanding of determinants in implementing discharge interventions for older adult patients' self-care. Our findings can inform tailored strategies for frontline staff, including aligning programme rationale with stakeholders, promoting staff engagement through co-creation, reinforcing positive programme outcomes and creating default settings. Future research should employ rigorous quantitative designs to examine the actual impact and relationships among these determinants.

Eliciting the barriers and enablers towards anaesthetists giving penicillin-based antibiotic prophylaxis to low-risk patients who have had their penicillin allergy label removed as part of a preoperative delabelling process

Background

Some penicillin allergy labels can be removed by non-allergy specialists by direct oral challenge, but there is reluctance amongst anaesthetists to give penicillin to these patients. We aimed to assess anaesthetist beliefs about giving penicillin to patients delabelled by direct oral challenge.

Methods

A survey, developed using the Theoretical Domains Framework, was circulated to anaesthetists within a regional research network in England. Domains were rated using 5-point Likert scales. Overall and group medians were used to dichotomize domains rated by group into 'relatively important/unimportant' and 'relative enabler/barrier'.

Results

We received 257 responses from six hospitals (response rate 49.7%). Seven domains were rated as important for all stakeholder groups and hospitals: Knowledge, Skills, Belief in Capabilities, Belief in Consequences, Memory/Attention/Decisions, Environmental Context and Resources, and Emotions. Social and Professional Role was also important to all respondents except those in one hospital. Intentions and Optimism were rated as important for some groups/hospitals and unimportant for others. All four other domains were rated as unimportant for all groups/hospitals. All domains rated as important were enablers for all groups/hospitals, with the exception of Memory/Attention/Decisions and Emotions, which were rated as discordant barriers/enablers between groups. This means they were acting as a barrier for some staff groups/hospitals and an enabler for others. Barrier domains (Reinforcement, Goals, Social Influences, Behavioural Regulation) were all rated unimportant.

Conclusions

Behavioural influences on giving penicillin prophylaxis to a delabelled patient are complex and nuanced. These findings could inform targeted interventions, both across and within hospitals and staff groups.

Putting weight-related conversations into practice: Lessons learned from implementing a knowledge translation casebook in a disability context

BACKGROUND

Due to reported challenges experienced by healthcare providers (HCPs) when having weight-related conversations with children with disabilities and their families, a knowledge translation (KT) casebook was developed, providing key communication principles with supportive resources. Our aim was to explore how the KT casebook could be implemented into a disability context. Study objectives were to develop and integrate needs-based implementation supports to help foster the uptake of the KT casebook communication principles.

METHODS

A sample of nurses, physicians, occupational therapists and physical therapists were recruited from a Canadian paediatric rehabilitation hospital. Informed by the Theoretical Domains Framework, group interviews were conducted with participants to understand barriers to having weight-related conversations in their context. Implementation strategies were developed to deliver the KT casebook content that addressed these identified barriers, which included an education workshop, simulations, printed materials, and a huddle and email strategy. Participant experiences with the implementation supports were captured through workshop evaluations, pre-post surveys and qualitative interviews. Post-implementation interviews were analysed using descriptive content analysis.

RESULTS

Ten HCPs implemented the KT casebook principles over 6 months. Participants reported that the workshop provided a clear understanding of the KT casebook content. While HCPs appreciated the breadth of the KT casebook, they found the abbreviated printed educational materials more convenient. Strategies developed to address participants' need for a sense of community and opportunities to learn from each other did not achieve their aim. Increased confidence in integrating the KT casebook principles into practice was not demonstrated, due, in part, to having few opportunities to practice. This was partly because of the increase in competing clinical demands at the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite positive feedback on the product itself, changes in the organisational and environmental context limited the success of the implementation plan. Monitoring and adapting implementation processes in response to unanticipated changes is critical to the success of implementation efforts.

The Predictors of Perceived Barriers and Facilitators of Applying Sepsis Six Guidelines Among Critical Care Nurses

BACKGROUND

Sepsis is a life-threatening condition that demands quick and cautious interventions from nurses, as they are the frontline caregivers, so they are essential in recognizing early signs of sepsis, initiating prompt healthcare interventions, and providing comprehensive care to improve patient outcomes. This study aimed to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

METHODS

This cross-sectional descriptive study was conducted on a convenience sample of 180 nurses working in critical care settings (ICU, critical care unit, ED, burning unit, dialysis unit) at a university hospital. A valid and reliable questionnaire was used to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

RESULTS

This study revealed that the main barriers faced by critical care nurses are lack of sepsis recognition during observational rounds and delay in sepsis diagnosis by medical staff. For the most common facilitators of applying Sepsis Six guidelines, the participating nurses reported the presence of a written tool/protocol for sepsis identification and management.

CONCLUSIONS

The study emphasized the importance of the presence of evidence-based protocols for sepsis assessment and management and nurses' compliance with guidelines. Ongoing education training for nurses and providing step-by-step written checklists are a cornerstone to improving nurses' knowledge and the practical skills of early identification and management of sepsis.

Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol

INTRODUCTION

Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs.

METHODS AND ANALYSIS

We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics.

ETHICS AND DISSEMINATION

The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities.

TRIAL REGISTRATION NUMBER

NCT05731349.

Nurses’ knowledge, attitudes, practice, and decision-making skills related to sepsis assessment and management

<b>Objectives</b>: The present study examines the critical care nurse’s knowledge, attitudes, practice (KAP), and decision-making related to early assessment and management of sepsis.<br /> <b>Methods</b>: This cross-sectional descriptive study utilized a convenience sample of 70 nurses working in a college hospital in the northern region of Jordan. Data were gathered employing a sepsis vignette and valid questionnaires via Google document. The nursing decision-making instrument and the knowledge, attitudes, and practice survey were utilized to assess nurses’ decision-making skills, knowledge, attitudes, and practice, respectively. Nurses’ sociodemographic/professional data, including gender, marital status, experience, education, and work environment, were also measured.<br /> <b>Result</b>: The participating nurses reported poor KAP, and analytical decision-making skills related to sepsis management. Experienced nurses and those with a master’s degree reported significantly better KAP, and intuitive decision-making skills than naïve and those with a bachelor’s degree. Nurses with analytical decision-making modes reported higher levels of knowledge, attitudes, and practice than nurses with intuitive or flexible analytical-intuitive decision-making modes.<br /> <b>Conclusion</b>: Poor decision-making skills, as well as knowledge, attitudes, and practice related to sepsis assessment and management, is a substantial problem that demands a productive re-evaluation of the current sepsis management practices. Boosting the knowledge and improving the practices on sepsis assessment and management through comprehensive educational programs and campaigns are necessary to improve nurses’ decision-making skills.

Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India

Background

The major cause of maternal death globally is postpartum hemorrhage (PPH). When PPH develops, early detection of bleeding and rapid treatment with evidence-based guidelines can prevent most PPH-related severe morbidity and mortality. The bundle care approach for PPH management could be a potential solution to inefficient and uneven evidence-based practice implementation worldwide. Bundle care is a collection of discrete, evidence-based interventions given to every eligible person simultaneously or in quick succession and requires teamwork, communication, and cooperation. The primary objective of this study was to analyze whether implementing a PPH bundle of care may reduce maternal morbidity and mortality in our institution.

Methods

This was a single-center retrospective pre-post case-control study was carried out at a tertiary care center and teaching hospital in Varanasi, eastern Uttar Pradesh state, India. From January 2021 to June 2021, pretraining data (PRE) were collected retrospectively on all births from the department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University. Subsequently, medical and paramedical personnel of our hospital were trained in Postpartum Hemorrhage Emergency Care Using a Bundle Approach (PPH EmC) as per the guidelines laid down by the World Health Organization (WHO) for PPH management and implemented in July 2021. Post-training data (POST) were then collected retrospectively on all deliveries at our hospital from August 2021 to January 2022. All the data within two periods were computed and analyzed. The results were then compared for any significant changes in the incidences of maternal mortality and morbidity in terms of the rates of blood transfusion required and the type of management used (medical or medical-surgical), use of tranexamic acid, and additional uterotonics. The results were expressed as proportions, and p≤0.05 was considered statistically significant using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 1304 women gave birth from January 2021 to January 2022, of whom 107 patients (61 in the PRE and 57 in the POST group) were diagnosed and treated for PPH. There was no significant difference in the incidence of PPH in the PRE and POST groups (p=0.581). There was a significant increase in the use of tranexamic acid (p=0.041) and a significant reduction in blood transfusion rates (p=0.032) after the implementation of bundled care in the POST group. The odds of PPH non-occurrence after pre- and post-test was 1.103 (95% CI=0.747 to 1.635). No significant difference was observed in maternal mortality in the PRE and POST groups (p=0.96). The requirement for radical surgical treatment of PPH, which included hysterectomies, was also significantly reduced, from 27.27% in the PRE group to 11.54% in the POST group (p=0.032).

Conclusions

PPH care bundles might improve the morbidity of PPH with the use of fewer resources and fewer interventions required. While these data are promising, further studies are needed to analyze bundle care's long-term effects.

Sepsis assessment and management in critically Ill adults: A systematic review

Background

Early assessment and management of patients with sepsis can significantly reduce its high mortality rates and improve patient outcomes and quality of life.

Objectives

The purposes of this review are to: (1) explore nurses’ knowledge, attitude, practice, and perceived barriers and facilitators related to early recognition and management of sepsis, (2) explore different interventions directed at nurses to improve sepsis management.

Methods

A systematic review method according to the PRISMA guidelines was used. An electronic search was conducted in March 2021 on several databases using combinations of keywords. Two researchers independently selected and screened the articles according to the eligibility criteria.

Results

Nurses reported an adequate of knowledge in certain areas of sepsis assessment and management in critically ill adult patients. Also, nurses’ attitudes toward sepsis assessment and management were positive in general, but they reported some misconceptions regarding antibiotic use for patients with sepsis, and that sepsis was inevitable for critically ill adult patients. Furthermore, nurses reported they either were not well-prepared or confident enough to effectively recognize and promptly manage sepsis. Also, there are different kinds of nurses’ perceived barriers and facilitators related to sepsis assessment and management: nurse, patient, physician, and system-related. There are different interventions directed at nurses to help in improving nurses’ knowledge, attitudes, and practice of sepsis assessment and management. These interventions include education sessions, simulation, decision support or screening tools for sepsis, and evidence-based treatment protocols/guidelines.

Discussion

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis in critical care patients.

Conclusion

Nurses have poor to good knowledge, practices, and attitudes toward sepsis as well as report many barriers related to sepsis management in adult critically ill patients. Despite all education interventions, no study has collectively targeted critical care nurses’ knowledge, attitudes, and practice of sepsis management.

The effectiveness of branching simulations in improving nurses' knowledge, attitudes, practice, and decision-making related to sepsis assessment and management

BACKGROUND

Nurses have a key role in the early assessment and management of sepsis, which is crucial for optimal quality of care and better patient outcomes. However, sepsis in critical care patients is underrecognized and untreated due to nurses' poor knowledge, attitudes, practice, and decision-making skills related to sepsis assessment and management.

OBJECTIVES

This study aimed to test the effectiveness of branching simulations in improving nurses' knowledge, attitudes, practices, and decision-making related to sepsis assessment and management.

METHODS

This experimental study was conducted on a convenience sample of 70 nurses (35 nurses in each of the intervention and control groups) with at least one year of experience working in an emergency room at a university hospital. The nurses' knowledge, attitudes, and practices were measured using a knowledge, attitudes, and practices survey, whilst their decision-making modes were assessed using the Nursing Decision-Making Instrument.

RESULTS

Compared to the control group, a significant improvement in practices (F _{(1, 68)} = 10.77, p = 0.002, η² = 0.137) and decision-making (F _{(1, 68)} = 10.68, p = 0.002, η² = 0.136) was observed among the nurses in the intervention group both immediately and two weeks post the branching simulations intervention. Compared to the baseline data, a significant improvement in knowledge (F _{(2, 136)} = 27.93, p < 0.001, η² = 0.291), practices (F _{(2, 136)} = 41.00, p < 0.001, η² = 0.376), and decision-making modes (F _{(2, 136)} = 29.15, p < 0.001, η² = 0.300) was observed both immediately and two weeks post branching simulations only among the nurses in the intervention group.

CONCLUSIONS

Education programs integrated with an interactive strategy of learning (branching simulations) can improve nurses' knowledge, attitude, practice, and decision-making related to sepsis assessment and management. Therefore, continuous education and professional training programs following an evidence-based intervention protocol/guideline are recommended for better nurse and patient outcomes.

Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis

Background

Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood.

Methods

We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors.

Results

We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)].

Conclusion

Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects.

PROSPERO Registration ID

CRD42021225417.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00558-5.

Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study

Background

Several health care systems internationally have implemented protocolised sepsis recognition and treatment bundles for children to improve outcomes, as recommended by the Surviving Sepsis Campaign. Successful implementation of clinical pathways is challenging and dependent on nurse engagement. There is limited data on knowledge translation during implementation of sepsis quality improvement programs.

Methods

This cross-sectional, multicentre observational survey study evaluated knowledge and perceptions of Emergency Department nurses in relation to the recognition, escalation and management of paediatric sepsis following implementation of a sepsis pathway. The study was conducted between September 2019 and March 2020 across 14 Emergency Departments in Queensland, Australia. The primary outcome was a sepsis knowledge score. An exploratory factor analysis was conducted to identify factors impacting nurses’ perceptions of recognition, escalation and management of paediatric sepsis and their association with knowledge. Using a logistic mixed effects model we explored associations between knowledge, identified factors and other clinical, demographic and hospital site variables.

Results

In total, 676 nurses responded to the survey and 534 were included in the analysis. The median knowledge score was 57.1% (IQR = 46.7–66.7), with considerable variation observed between sites. The exploratory factor analysis identified five factors contributing to paediatric sepsis recognition, escalation and management, categorised as 1) knowledge and beliefs, 2) social influences, 3) beliefs about capability and skills delivering treatment, 4) beliefs about capability and behaviour and 5) environmental context. Nurses reported strong agreement with statements measuring four of the five factors, responding lowest to the factor pertaining to capability and skills delivering treatment for paediatric sepsis. The factors knowledge and beliefs, capability and skills, and environmental context were positively associated with a higher knowledge score. Years of paediatric experience and dedicated nurse funding for the sepsis quality improvement initiative were also associated with a higher knowledge score.

Conclusion

Translation of evidence to practice such as successful implementation of a sepsis care bundle, relies on effective education of staff and sustained uptake of protocols in daily practice. Our survey findings identify key elements associated with enhanced knowledge including dedicated funding for hospitals to target paediatric sepsis quality improvement projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07128-2.

Sepsis knowledge, skills and attitudes among ward-based nurses

BACKGROUND

Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low.

AIMS

To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses.

METHODS

Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire.

FINDINGS

Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis.

CONCLUSIONS

Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.

Sepsis scoring systems and use of the Sepsis six care bundle in maternity hospitals

BACKGROUND

This study aimed to assess the predictive power of three different Sepsis Scoring Systems (SSSs), namely maternity Systematic Inflammatory Response Syndrome (mSIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) and Modified Early Warning System (MEWS) in identifying sepsis by comparing them with positive culture. This study also sought to evaluate compliance with using the Sepsis Six Care Bundle (SSCB) operated in an individual health board.

METHODS

A retrospective cohort study was conducted in 3 maternity hospitals of a single Scottish health board that admitted 2690 pregnancies in a 12 weeks period in 2016. Data for study was obtained from medical notes, handheld and electronic health records for women who were prescribed antibiotics with a confirmed or suspected diagnosis of sepsis. Data on clinical parameters was used to classify women according to mSIRS, qSOFA and MEWS as having sepsis or not and this was compared to results of positive culture to obtain sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under Receiver Operating Characteristic curve (AUROC) along with their 95% confidence intervals. Data was also obtained on SSCB compliance.

RESULTS

A total of 89 women were diagnosed with sepsis, of which 14 had missing data, leaving 75 for final analysis. Sensitivity, specificity, PPV, NPV and AUROC of mSIRS and MEWS were almost similar with AUROC of both being around 50%. Only 33 (37.1%) had identifiable sepsis six sticker displayed on medical notes and only 2 (2.2%) had all elements of SSCB delivered within the recommended one-hour post-diagnosis period. Blood culture and full blood count with other lab tests had been performed for most women (97%) followed by intravenous antibiotics and fluids (93.9%).

CONCLUSIONS

mSIRS and MEWS were quite similar in detecting sepsis when compared to positive culture, with their ability to detect sepsis being close to chance. This underlines the need for creating a valid SSS with high sensitivity and specificity for clinical use in obstetric settings. Clinical use of SSCB was limited despite it being a health board policy, although there is considerable possibility of improvement following detailed audits and removal of barriers for implementing SSCB.

Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a 'clinical care bundle' for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the "E-MOTIVE" bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice.

METHODS

We will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops.

DISCUSSION

This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04341662.

Improving the Accuracy of Sepsis Screening by Nurses in Hospitalized Older Adults: A Pilot Interventional Study

The current quality improvement interventional study aimed to determine whether an educational intervention focused on evidence-based practices of sepsis screening for RNs would increase accuracy of sepsis screenings performed among older adult patients in a 32-bed medical-surgical unit of a large urban trauma hospital. A total of 34 RNs participated in this study. Sepsis screenings of participants were collected and audited before and after the educational intervention to determine changes in sepsis screening accuracy. A dependent samples t test was used to assess the statistical difference between pre- and post-intervention sepsis screening scores. Results indicated that the educational intervention effectively increased sepsis screening accuracy in older adult patients at the study center (p = 0.007), with a mean increase of 22.06% accuracy. Accurate sepsis screening is crucial for early sepsis diagnosis and treatment to improve the clinical outcomes of older adult patients with sepsis, reduce health care costs, and decrease resource use. [Journal of Gerontological Nursing, 47(6), 27-34.].

Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: A theory-driven interview study using the Theoretical Domains Framework

AIM

To explore barriers and enablers of recognition and response to signs of patient deterioration by nursing staff in an acute hospital.

DESIGN

A theory-driven interview study underpinned by the Theoretical Domains Framework of behaviour change.

METHODS

Between 07/01/2019 and 18/12/2019 a purposive sample of registered nurses and healthcare assistants was recruited to participate in a semi-structured (audio-recorded) interview, to explore the determinants of seven specified behaviours of the afferent limb. Anonymised transcripts were deductively coded (using the 14 Theoretical Domains Framework domains as coding categories) and then extracts within each domain were inductively analysed to synthesise belief statements and themes. Prioritisation criteria from published literature were applied.

RESULTS

Thirty-two semi-structured interviews were conducted. From 1,888 quotes, 184 belief statements and 66 themes were synthesised. One hundred and forty-six belief statements, represented by 58 themes, met prioritisation criteria. Nine domains of the Theoretical Domains Framework were of high importance: Knowledge; Social, Professional Role and Identity; Beliefs about Consequences; Reinforcement; Intentions; Goals; Memory, Attention and Decision Processes; Environment, Context and Resources and Social Influences.

CONCLUSIONS

Barriers and enablers most likely to impact on nursing staff afferent limb behaviour were identified in nine domains of the Theoretical Domains Framework.

Effectiveness of the sepsis six bundle in the management of acute adult sepsis in the UK

There are up to 11 million sepsis-related deaths worldwide each year. Management of sepsis requires early recognition, appropriate antibiotic treatment and careful management of haemodynamic status. In 2006, the UK Sepsis Trust introduced the sepsis six care bundle to simplify the guidelines for managing sepsis and identify actions for management that were more accessible to junior clinicians. This article reports findings from a literature review that explored the effectiveness of the sepsis six bundle in the management of adult sepsis patients in the UK and assessed the level of clinician compliance in UK clinical settings. The effectiveness of sepsis six was based on patient mortality during hospital stay, rate of intensive care unit admissions and length of hospital stay, all of which were found to have improved since the introduction of the tool.

Barriers and facilitators to infection prevention and control in a neonatal unit in Zimbabwe - a theory-driven qualitative study to inform design of a behaviour change intervention

BACKGROUND

Hospital-acquired infection (HAI) is an increasing cause of neonatal morbidity/mortality in low-income settings. Hospital staff behaviours (e.g., hand hygiene) are key contributors to HAI. Understanding the drivers of these can inform interventions to improve infection prevention and control (IPC).

AIM

To explore barriers/facilitators to IPC in a neonatal unit in Harare, Zimbabwe.

METHODS

Interviews were conducted with 15 staff members of neonatal and maternity units alongside ethnographic observations. The interview guide and data analysis were informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model and explored individual, socio-cultural, and organizational barriers/facilitators to IPC. Potential interventions were identified using the Behaviour-Change Wheel.

FINDINGS

Enablers within Capability included awareness of IPC, and within Motivation beliefs that IPC was crucial to one's role, and concerns about consequences of poor IPC. Staff were optimistic that IPC could improve, contingent upon resource availability (Opportunity). Barriers included: limited knowledge of guidelines, no formal feedback on performance (Capability), lack of resources (Opportunity), often leading to improvization and poor habit formation. Further barriers included the unit's hierarchy, e.g., low engagement of cleaners and mothers in IPC, and staff witnessing implementation of poor practices by other team members (Opportunity). Potential interventions could include role-modelling, engaging mothers and staff across cadres, audit and feedback and flexible protocols (adaptable to water/handrub availability).

CONCLUSIONS

Most barriers to IPC fell within Opportunity, whilst most enablers fell under Capability and Motivation. Theory-based investigation provides the basis for systematically identifying and developing interventions to address barriers and enablers to IPC in low-income settings.

A Qualitative Study Investigating the Barriers to the Implementation of the ‘Sepsis Six Care Bundle’ in Maternity Wards

Background: In 2014, the Sepsis Six Care Bundle (SSCB) was introduced into a Scottish health region to improve patient outcomes. Poor compliance was demonstrated with the SSCB across different specialities. This study explored determinants of non-compliance with the SSCB in maternity wards. Methods: In-depth interviews were conducted with midwives in a single Scottish health region. Convenience sampling was used to recruit interviewees. The interviews were digitally recorded, transcribed verbatim, entered into NVivo software, and analysed using thematic analysis. Results: Thirteen face-to-face interviews were completed and lasted an average of 33 min. Three main barriers were identified to SSCB implementation; the difficulty of diagnosing sepsis, the suitability of the SSCB in a maternity setting as part of the pre-conditions phase, and the lack of staff training as part of the pre-implementation phase. Conclusion: The findings emphasize the importance of adapting improvement initiatives with sufficient preparation of staff in the rationale use to the context of care bundles.

To call or not to call: behavioral determinants influencing the decision of intensivists to consult poison centers for calcium channel blocker poisoning

Purpose: This study aimed to define the behavioral determinants influencing the decision of intensivists to consult a poison center (PC) when managing patients with calcium channel blocker (CCB) poisoning.Material and methods: Semi-structured interviews were conducted involving a convenience sample of 18 intensivists. Two independent reviewers analyzed the interview responses using the Theoretical Domains Framework. Based on the impact and frequency of the reported behaviors, we selected the most relevant domains likely to influence intensivists' decision to consult a PC for CCB poisoning.Results: Beliefs influencing physicians positively to consult a PC for CCB poisoning were identified in the following domains: knowledge (e.g., lower level of evidence), social or professional role and identity (e.g., high credibility attributed to the PC), reinforcement (e.g., multiple drug poisoning, infrequent or potentially lethal poisoning, medicolegal considerations), and behavioral regulation (e.g., facilitated access of PC to patient's hospital chart, direct communication with a toxicologist). Beliefs deterring physicians from consulting a PC for CCB poisoning were identified in the following domains: knowledge (e.g., better awareness of recommendations decreases tendency to call), goals (e.g., priority for patient stabilization), and memory, attention, and decision process (e.g., cognitive overload due to an unstable patient).Conclusion: This qualitative study identified potential behavioral targets that future implementation strategies should address to improve collaboration between PCs and intensivists. In light of our results, the Québec PC now asks clinicians if the poisoned patient is unstable prior to collecting any other information. When necessary, a teleconference with the toxicologist is proposed earlier than before.

Driving sustainable change in antimicrobial prescribing practice: how can social and behavioural sciences help?

Addressing the growing threat of antimicrobial resistance is, in part, reliant on the complex challenge of changing human behaviour-in terms of reducing inappropriate antibiotic use and preventing infection. Whilst there is no 'one size fits all' recommended behavioural solution for improving antimicrobial stewardship, the behavioural and social sciences offer a range of theories, frameworks, methods and evidence-based principles that can help inform the design of behaviour change interventions that are context-specific and thus more likely to be effective. However, the state-of-the-art in antimicrobial stewardship research and practice suggests that behavioural and social influences are often not given due consideration in the design and evaluation of interventions to improve antimicrobial prescribing. In this paper, we discuss four potential areas where the behavioural and social sciences can help drive more effective and sustained behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii) adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and detailed intervention reporting.

Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer

OBJECTIVE

We examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients.

METHODS

Patients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients' medical records.

RESULTS

Multivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02).

CONCLUSIONS

Assessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.

Barriers and Facilitators of Intensivists' Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning

INTRODUCTION

Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning.

METHODS

Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning.

RESULTS

Positive beliefs were identified in the following domains: "behavioral regulation" (e.g., algorithm for adjustment of perfusions), "belief about capabilities" (e.g., confidence about being able to manage HIET), "belief about consequences" (e.g., fear of clinical deterioration), and "reinforcement" (e.g., clinical instability). Negative beliefs were identified in the following domains as "nature of behavior" (e.g., preference for vasopressors over HIET) and "environmental context and resources" (e.g., accessing dextrose 50% and increased nurse workload).

CONCLUSION

This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.

Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs

Infection and sepsis are common problems in cancer management affecting up to 45% of patients and are associated with significant morbidity, mortality and healthcare utilisation.

Objective

To develop and implement a whole of hospital clinical pathway for the management of sepsis (SP) in a specialised cancer hospital and to measure the impact on patient outcomes and healthcare utilisation.

Methods

A multidisciplinary sepsis working party was established. Process mapping of practices for recognition and management of sepsis was undertaken across all clinical areas. A clinical pathway document that supported nurse-initiated sepsis care, prompt antibiotic and fluid resuscitation was implemented. Process and outcome measures for patients with sepsis were collected preimplementation (April-December 2012), postimplementation cohorts (April-December 2013), and from January to December 2014.

Results

323 patients were evaluated (111 preimplementation, 212 postimplementation). More patients with sepsis had lactate measured (75.0% vs 17.2%) and appropriate first dose antibiotic (90.1% vs 76.1%) (all p<0.05). Time to antibiotics was halved (55 vs 110 min, p<0.05). Patients with sepsis had lower rates of intensive care unit admission (17.1% vs 35.5%), postsepsis length of stay (7.5 vs 9.9 days), and sepsis-related mortality (5.0% vs 16.2%) (all p<0.05). Mean total hospital admission costs were lower in the SP cohort, with a significant difference in admission costs between historical and SP non-surgical groups of $A8363 (95% CI 81.02 to 16645.32, p=0.048) per patient on the pathway. A second cohort of 449 patients with sepsis from January to December 2014 demonstrated sustained improvement.

Conclusions

The SP was associated with significant improvement in patient outcomes and reduced costs. The SP has been sustained since 2013, and has been successfully implemented in another hospital with further implementations underway in Victoria.