Study protocol for two randomized controlled trials examining the effectiveness and safety of current weekend allied health services and a new stakeholder-driven model for acute medical/surgical patients versus no weekend allied health services

How Can Implementation Science Improve the Care of Familial Hypercholesterolaemia?

PURPOSE OF REVIEW

Describe the application of implementation science to improve the detection and management of familial hypercholesterolaemia.

RECENT FINDINGS

Gaps between evidence and practice, such as underutilization of genetic testing, family cascade testing, failure to achieve LDL-cholesterol goals and low levels of knowledge and awareness, have been identified through clinical registry analyses and clinician surveys. Implementation science theories, models and frameworks have been applied to assess barriers and enablers in the literature specific to local contextual factors (e.g. stages of life). The effect of implementation strategies to overcome these factors has been evaluated; for example, automated identification of individuals with FH or training and education to improve statin adherence. Clinical registries were identified as a key infrastructure to monitor, evaluate and sustain improvements in care. The expansion in evidence supporting the care of familial hypercholesterolaemia requires a similar expansion of efforts to translate new knowledge into clinical practice.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BACKGROUND

Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.

METHODS AND FINDINGS

This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.

CONCLUSIONS

Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Moving Past the Loss: A Longitudinal Qualitative Study of Health Care Staff Experiences of Disinvestment

This longitudinal qualitative study examines staff experience of disinvestment from a service they are accustomed to providing to their patients. It took place alongside a disinvestment trial that measured the impact of the removal of weekend allied health services from acute wards at two hospitals. Data were gathered from repeated interviews and focus groups with 450 health care staff. We developed a grounded theory, which explains changes in staff perceptions over time and the key modifying factors. Staff appeared to experience disinvestment as loss; a key difference to other operational changes. Early staff experiences of disinvestment were primarily negative, but evolved with time and change-management strategies such as the provision of data, clear and persistent communication approaches, and forums where the big picture context of the disinvestment was robustly discussed. These allowed the disinvestment trial to be successfully implemented at two health services, with high compliance with the research protocol.

The effect of transferring weekend physical therapy services from the acute to sub-acute setting in patients following hip and knee arthroplasty: a quasi-experimental study

BACKGROUND

Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited.

PURPOSE

To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty.

METHODS

This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted.

RESULTS

The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p = .022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively).

CONCLUSIONS

No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients.

Increased allied health services to general and acute medical units decreases length of stay: comparison with a historical cohort

Objective The present study evaluated the effect of an initiative to fund increased allied health (AH) services, enabling increased days and both volume and scope of AH services, for general medical in-patients in the Central Adelaide Local Health Network for a 6-month trial period. Methods A quasi-experimental mixed-methods study was undertaken involving general medical in-patients at two acute tertiary-referral public hospitals with a prospective (December 2015-May 2016) and historical comparison (December 2014-May 2015) cohort. Outcome measures compared between the two cohorts included hospital length of stay (LOS), occupied bed-days, adverse events and AH service data. Results After implementation of increased AH services, there were significant decreases in the median (interquartile range) of both hospital LOS (from 7.2 (7.0-8.0) to 6.5 (6.1-6.7) days; P=0.006) and occupied bed-days (from 5295.0 (5200.0-5622.3) to 4662.5 (4335.8-4744.3) bed-days per month; P=0.004). There was no significant change in weekend discharges or adverse events. AH services increased, with the median number of referrals seen by AH professionals per month, occasions of AH service and AH intervention time per month increasing by 17%, 45% and 43% respectively after implementation, along with a faster response time to referrals. Conclusions Increased levels of AH staffing to general medical in-patients were associated with a significant reduction in hospital LOS and occupied bed-days. What is known about the topic? AH services are an important component in the delivery of safe, effective and efficient health care to hospitalised patients. There is little evidence specifically investigating the effect of increased AH services for general medical patients in an acute hospital setting. What does this paper add? This study provides new evidence demonstrating that increasing AH services to general medical in-patients within two acute tertiary-referral public hospitals decreased hospital LOS and occupied bed-days, without an increase in adverse events. What are the implications for practitioners? A funding initiative to enable increased AH services to general medical in-patients significantly reduced hospital LOS and occupied bed-days. These findings will be of considerable interest to other healthcare centres, particularly those where AH levels are below benchmark figures.

Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia: A Stepped-Wedge Randomized Clinical Trial

IMPORTANCE

Community-acquired pneumonia remains a leading cause of hospitalization, mortality, and health care costs worldwide. Randomized clinical trials support the use of adjunctive corticosteroids, early progressive mobilization, antibiotic switching rules, and dietary interventions in improving outcomes. However, it is uncertain whether implementing these interventions will translate into effectiveness under routine health care conditions.

OBJECTIVE

To evaluate the effectiveness of a bundle of evidence-supported treatments under conditions of routine care in a representative population hospitalized for community-acquired pneumonia.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, stepped-wedge, cluster-randomized clinical trial with 90-day follow-up was conducted between August 1, 2016, and October 29, 2017, in the general internal medicine service at 2 tertiary hospitals in Melbourne, Australia, among a consecutive sample of patients with community-acquired pneumonia. The primary analysis and preparation of results took place between May 14 and November 25, 2018.

INTERVENTIONS

Treating clinical teams were advised to prescribe prednisolone acetate, 50 mg/d, for 7 days (in the absence of any contraindication) and de-escalate from parenteral to oral antibiotics according to standardized criteria. Algorithm-guided early mobilization and malnutrition screening and treatment were also implemented.

MAIN OUTCOMES AND MEASURES

Hospital length of stay, mortality, readmission, and intervention-associated adverse events (eg, gastrointestinal bleeding and hyperglycemia).

RESULTS

A total of 917 patients were screened, and 816 (351 women and 465 men; mean [SD] age, 76 [13] years) were included in the intention-to-treat analysis, with 401 patients receiving the intervention and 415 patients in the control group. An unadjusted geometric mean ratio of 0.95 (95% CI, 0.78-1.16) was observed for the difference in length of stay (days) between the intervention and control groups. Similarly, no significant differences were observed for the secondary outcomes of mortality and readmission, and the results remained unchanged after further adjustment for sex and age. The study reported higher proportions of gastrointestinal bleeding in the intervention group (9 [2.2%]) compared with the controls (3 [0.7%]), with an unadjusted estimated difference in mean proportions of 0.008 (95% CI, 0.005-0.010).

CONCLUSIONS AND RELEVANCE

This bundled intervention including adjunctive corticosteroids demonstrated no evidence of effectiveness and resulted in a higher incidence of gastrointestinal bleeding. Efficacy of individual interventions demonstrated in clinical trials may not necessarily translate into effectiveness when implemented in combination and may even result in net harm.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02835040.

Early inpatient rehabilitation for acutely hospitalized older patients: a systematic review of outcome measures

Background

Selecting appropriate outcome measures for vulnerable, multimorbid, older patients with acute and chronic impairments poses specific challenges, which may have caused inconsistent findings of previous intervention trials on early inpatient rehabilitation in acutely hospitalized older patients. The aim of this review was to describe primary outcome measures that have been used in randomized controlled trials (RCTs) on early rehabilitation in acutely hospitalized older patients, to analyze their matching, and to evaluate the effects of matching on the main findings of these RCTs.

Methods

A systematic literature search was conducted in PubMed, Cochrane CENTRAL, CINAHL, and PEDro databases. Additional studies were identified through reference and citation tracking. Inclusion criteria were: RCT, patients aged ≥65 years, admission to an acute hospital medical ward (but not to an intensive medical care unit), physical exercise intervention (also as part of multidisciplinary programs), and primary outcome measure during hospitalization. Two independent reviewers extracted the data, assessed the methodological quality, and analyzed the matching of primary outcome measures to the intervention, study sample, and setting. Main study findings were related to the results of the matching procedure.

Results

Twenty-eight articles reporting on 24 studies were included. A total of 33 different primary outcome measures were identified, which were grouped into six categories: functional status, mobility status, hospital outcomes, adverse clinical events, psychological status, and cognitive functioning. Outcome measures differed considerably within each category and showed a large heterogeneity in their matching to the intervention, study sample, and setting. Outcome measures that specifically matched the intervention contents were more likely to document intervention-induced benefits. Mobility instruments seemed to be the most sensitive outcome measures to reveal such benefits.

Conclusions

This review highlights that the selection of outcome measures has to be highly specific to the intervention contents as this is a key factor to reveal benefits attributable to early rehabilitation in acutely hospitalized older patients. Inappropriate selection of outcome measures may represent a major cause of inconsistent findings reported on the effectiveness of early rehabilitation in this setting.

Trial registration

PROSPERO CRD42017063978.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1201-4) contains supplementary material, which is available to authorized users.

Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study

Background: Disinvestment from inefficient health services may be a potential solution to rising healthcare costs, but there has been poor uptake of disinvestment recommendations. This Australian study aims to understand how health professionals react when confronted with a plan to disinvest from a health service they previously provided to their patients.

Methods: This qualitative study took place prior to the disinvestment phase of a trial which removed weekend allied health services from acute hospital wards, to evaluate the effectiveness and cost effectiveness of the service. Observations and focus groups were used to collect data from 156 participants which was analysed thematically.

Results: Initial reactions to the disinvestment were almost universally negative, with staff extremely concerned about the impact on the safety and quality of patient care and planning ways to circumvent the trial. Removal of existing services was perceived as a loss and created a direct threat to some clinicians’ professional identity. With time, discussion, and understanding of the project’s context, some staff moved towards acceptance and perceived the trial as an opportunity, particularly given the service was to be reinstated after the disinvestment.

Conclusion: Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.

Impact of the "Weekend Effect" for Hospital Discharges on Readmissions After Elective Colectomy

BACKGROUND

Hospital readmissions after elective colectomy are costly and potentially preventable. It is unknown whether hospital discharge on a weekend impacts readmission risk.

OBJECTIVE

This study aimed to use a national database to determine whether discharge on a weekend versus weekday impacts the risk of readmission, and to determine what discharge-related factors impact this risk.

DESIGN

This investigation is a retrospective cohort study.

SETTINGS

Data were derived from the University HealthSystem Consortium, PATIENTS:: Adults who underwent elective colectomy from 2011 to 2015 were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the 30-day hospital readmission rate.

RESULTS

Of the 76,031 patients who survived the index hospitalization, the mean age of the study population was 58 years; half were men and more than 75% were white. Overall, 20,829 (27%) were discharged on the weekend, and the remaining 55,202 (73%) were discharged on weekdays. The overall 30-day readmission rate was 10.5%; 8.9% for those discharged on the weekend vs 11.1% for those discharged during the weekday (unadjusted OR, 0.78; 95% CI, 0.74-0.83). The adjusted readmission risk was lower for patients discharged home without services (routine, without organized home health service) on a weekend compared with on a weekday (adjusted OR, 0.87; 95% CI, 0.81-0.93; readmission rates, 7.4% vs 8.9%, p < 0.001); however, the combination of weekend discharge and the need for home services increased readmission risk (adjusted OR, 1.39; 95% CI, 1.25-1.55; readmission rate, 16.2% vs 8.9%, p < 0.001). Although patients discharged to rehabilitation and skilled nursing facilities were at an increased risk of readmission compared with those discharged to home, there was no additive increase in risk of readmission for weekend discharge.

LIMITATIONS

Data did not capture readmission beyond 30 days or to nonindex hospitals.

CONCLUSIONS

Patients discharged on a weekend following elective colectomy were at increased risk of readmission compared with patients discharged on a weekday if they required organized home health services. Further prospective studies are needed to identify areas of intervention to improve the discharge infrastructure. See Video Abstract at http://links.lww.com/DCR/A799.

Health professionals' perceptions of the allied health role in the acute setting following hip and knee joint replacement surgery: a qualitative study

Purpose: To describe health professionals' perceptions of the role of allied health during the acute phase following elective lower limb joint replacement surgery to inform the development of efficient allied health service models.Methods: This was a qualitative descriptive study conducted using semi-structured focus groups and thematic analysis. Participants were 25 medical, nursing, and allied health professionals working on two orthopaedic wards in a tertiary hospital in Victoria, Australia. Focus groups elicited staff perceptions regarding the aims and roles of acute allied health intervention following hip and knee replacement, how these services are currently provided, and how these services can best be provided. This study was undertaken alongside two stepped wedge cluster randomised controlled trials during which existing weekend allied health services were to be temporarily removed with opportunity to contribute to a stakeholder-driven model of these services.Results: The main theme that emerged was a sense of unrealised potential amongst health professionals in terms of patient outcomes following hip and knee joint replacement surgery arising from tension between perceptions of actual versus ideal allied health practice. Assessing function and planning for discharge accordingly was perceived to be a higher priority than intervening to improve functional independence.Conclusion: Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in patients following lower limb replacement surgery than current practice in this setting that prioritises discharge.Implications for RehabilitationAllied health service delivery in the acute phase following hip and knee joint replacement needs to balance the needs of the health service with those of the patients.Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in this population than current practice, which is to prioritise discharge.There may be more scope for nurses to be involved in promoting early postoperative mobilisation following joint replacement surgery, especially in uncomplicated cases.

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

QUESTION

Are additional weekend allied health services effective and cost-effective for acute general medical and surgical wards, and subacute rehabilitation hospital wards?

DESIGN

Systematic review and meta-analysis of studies published between January 2000 and May 2017. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta-analyses were conducted for relative measures of effect estimates.

PARTICIPANTS

Patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards.

INTERVENTION

All services delivered by allied health professionals during weekends (Saturday and/or Sunday). This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants.

OUTCOME MEASURES

Hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health-related quality of life, and cost of hospital care.

RESULTS

Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised, controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35days (95% CI 0.45 to 4.24, I²=0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI -0.01 to 0.19, I²=0%), and health-related quality of life (SMD 0.10, 95% CI -0.01 to 0.20, I²=0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION

The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.

REGISTRATION

PROSPERO CRD76771. [Sarkies MN, White J, Henderson K, Haas R, Bowles J, Evidence Translation in Allied Health (EviTAH) Group (2018) Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review. Journal of Physiotherapy 64: 142-158].

Postgraduate clinical physiotherapy education in acute hospitals: a cohort study

Background: Junior physiotherapists require satisfactory clinical skills to work effectively within the acute hospital setting for service quality and consistency. Objective: To investigate the effects of stream-specific clinical training on junior physiotherapist self-efficacy, self-rated confidence, and self-rated ability to work independently during weekend shifts. Design: Prospective cohort study. Participants: Eighteen junior physiotherapists. Methods: Physiotherapists undertook 8 h of stream-specific education in: pediatrics, women's health, neuro-medical, musculoskeletal, cardiorespiratory, and critical care over 8 weeks. Learning objectives were evaluated using a self-efficacy (0-100) scale and self-rated confidence was measured with a 4-point Likert scale (not confident to independent). Self-rated ability to independently work weekend shifts was measured dichotomously (yes/no). Results: Participants completed an average of three stream-specific programs in the study period. Post-training, mean improvement in self-efficacy across objectives ranged from 2.9 (95% CI -8.7 to 14.5) to 43.3 (95% CI 4.8-81.8) points, p < 0.05 for 80% of objectives. Self-rated confidence scores improved for 45.6% of stream-specific learning objectives; 52.8% were unchanged and 1.7% reported a decrease in confidence. Self-rated ability to work stream-specific weekend shifts increased from 56-70%, but no stream achieved a significant increase in staff able to independently work weekend shifts (p range 0.10 to 1.0). Conclusions: A stream-specific education program increased junior physiotherapists' self-efficacy and self-rated confidence but not perceived ability to work independently on weekends. Results were non-randomized and actual practice change was not assessed. Future studies could investigate different educational structures in a blinded, randomized manner on clinical practice change.

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol

BACKGROUND

It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers.

METHODS

This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up.

DISCUSSION

Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Effects of Structured Exercise Interventions for Older Adults Hospitalized With Acute Medical Illness: A Systematic Review

This review examined effects of structured exercise (aerobic walking, with or without complementary modes of exercise) on cardiorespiratory measures, mobility, functional status, healthcare utilization, and quality of life in older adults (≥60 years) hospitalized for acute medical illness. Inclusion required exercise protocol, at least one patient-level or utilization outcome, and at least one physical assessment point during hospitalization or within 1 month of intervention. MEDLINE, Embase, and CINAHL databases were searched for studies published from 2000 to March 2015. Qualitative synthesis of 12 articles, reporting on 11 randomized controlled trials (RCTs) and quasi-experimental trials described a heterogeneous set of exercise programs and reported mixed results across outcome categories. Methodological quality was independently assessed by two reviewers using the Cochrane Collaboration Risk of Bias tool. Larger, well-designed RCTs are needed, incorporating measurement of premorbid function, randomization with intention-to-treat analysis, examination of a targeted intervention with predefined intensity, and reported adherence and attrition.

The IMPROVE-GAP Trial aiming to improve evidence-based management of community-acquired pneumonia: study protocol for a stepped-wedge randomised controlled trial

Background

Community-acquired pneumonia is a leading worldwide cause of hospital admissions and healthcare resource consumption. The largest proportion of hospitalisations now occurs in older patients, with high rates of multimorbidity and complex care needs. In Australia, this population is usually managed by hospital inpatient general internal medicine units. Adherence to consensus best-practice guidelines is poor. Ensuring evidence-based care and reducing length of stay may improve patient outcomes and reduce organisational costs. This study aims to evaluate an alternative model of care designed to improve adherence to four Level 1 or 2 evidence-supported interventions (routine corticosteroids, early switch to oral antibiotics, early mobilisation and routine malnutrition screening).

Methods/Design

The IMPROVing Evidence-based treatment Gaps and outcomes in community-Acquired Pneumonia (IMPROVE-GAP) trial is a pragmatic, investigator-initiated, stepped-wedge randomised trial. Patients hospitalised under a general internal medicine unit who meet a standard case definition for community-acquired pneumonia will be included. Eight general internal medicine units at two Australian hospitals in a single health service will be randomised using concealed allocation to: (i) usual medical, nursing and allied health care delivered according to existing organisational practice or (ii) care supported by a dedicated “community-acquired pneumonia service”: a multidisciplinary team deploying algorithm-based implementation of a bundle of the four evidence-based interventions. The primary outcome measure will be length of hospital stay. Secondary outcome measures include inpatient mortality, 30 and 90 day readmission rates and mortality and health-service utilisation costs. Protocol adherence will be measured and reported, and serious adverse events (rates of hyperglycaemia requiring new insulin; falls during mobilisation) will be collected and reported.

Discussion

IMPROVE-GAP represents an important and unique precedent for testing a new service-delivery model for improving compliance with a number of evidence-based interventions. Its stepped-wedge randomised controlled trial design provides a means to address some significant ethical, organisational and other methodological challenges to evaluating the effectiveness of health-service interventions in complex hospital populations. The new service-delivery model will effectively be fully implemented by trial completion, facilitating rapid, seamless translation into practice should care outcomes be superior. This trial is currently recruiting.

Trial registration

ClinicalTrials.gov, NCT02835040. Prospectively registered on 22 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2407-4) contains supplementary material, which is available to authorized users.

Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials

BACKGROUND

Disinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design.

METHODS AND FINDINGS

We conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the 'current' weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a 'newly developed' service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The 'no weekend allied health service' condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated effect size difference between groups in the proportion of patients staying longer than expected (weekend versus no weekend; estimated effect size difference [95% CI], p-value) in Trial 1 (0.40 versus 0.38; estimated effect size difference 0.01 [-0.01 to 0.04], p = 0.31, CI was both above and below non-inferiority margin), but the proportion staying longer than expected was greater with the newly developed service compared to its no weekend service control condition (0.39 versus 0.40; estimated effect size difference 0.02 [0.01 to 0.04], p = 0.04, CI was completely below non-inferiority margin) in Trial 2. Trial 1 and 2 findings were discordant for the mean length of stay outcome (Trial 1: 5.5 versus 6.3 days; estimated effect size difference 1.3 days [0.9 to 1.8], p < 0.001, CI was both above and below non-inferiority margin; Trial 2: 5.9 versus 5.0 days; estimated effect size difference -1.6 days [-2.0 to -1.1], p < 0.001, CI was completely below non-inferiority margin). There was no difference between conditions for the proportion who had an unplanned readmission within 28 days in either trial (Trial 1: 0.01 [-0.01 to 0.03], p = 0.18, CI was both above and below non-inferiority margin; Trial 2: -0.01 [-0.02 to 0.01], p = 0.62, CI completely below non-inferiority margin). There was no difference between conditions in the proportion of patients who experienced any adverse event in Trial 1 (0.01 [-0.01 to 0.03], p = 0.33, CI was both above and below non-inferiority margin), but a lower proportion of patients had an adverse event in Trial 2 when exposed to the no weekend allied health condition (-0.03 [-0.05 to -0.004], p = 0.02, CI completely below non-inferiority margin). Limitations of this research were that 1 of the trial wards was closed by the healthcare provider after Trial 1 and could not be included in Trial 2, and that both withdrawing the current weekend allied health service model and installing a new one may have led to an accommodation period for staff to adapt to the new service settings. Stepped-wedge trials are potentially susceptible to bias from naturally occurring change over time at the service level; however, this was adjusted for in our analyses.

CONCLUSIONS

In Trial 1, criteria to say that the no weekend allied health condition was non-inferior to current weekend allied health condition were not met, while neither the no weekend nor current weekend allied health condition demonstrated superiority. In Trial 2, the no weekend allied health condition was non-inferior to the newly developed weekend allied health condition across all primary outcomes, and superior for the outcomes proportion of patients staying longer than expected, proportion experiencing any adverse event, and mean length of stay.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001231730 and ACTRN12613001361796.

What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers

Background

There is strong public support for acute hospital services to move to genuine 7-day models, including access to multidisciplinary team assessment. This study aimed to identify factors that might enable an effective and cost-effective weekend allied health services on acute hospital wards.

Methods

This qualitative study included 22 focus groups within acute wards with a weekend allied health service and 11 telephone interviews with weekend service providers. Data were collected from 210 hospital team members, including 17 medical, 97 nursing, and 96 allied health professionals from two Australian tertiary public hospitals. All were recorded and imported into nVivo 10 for analysis. Thematic analysis methods were used to develop a coding framework from the data and to identify emerging themes.

Results

Key themes identified were separated into issues perceived as being enablers or barriers to the effective or cost-effective delivery of weekend allied health services. Perceived enablers of effectiveness and cost-effectiveness included prioritizing interventions that prevent decline, the right person delivering the right service, improved access to the patient’s family, and ability to impact patient flow. Perceived barriers were employment of inexperienced weekend staff, insufficient investment to see tangible benefit, inefficiencies related to double-handling, unnecessary interventions and/or inappropriate referrals, and difficulty recruiting and retaining skilled staff.

Conclusions

Suggestions for ensuring effective and cost effective weekend allied health care models include minimization of task duplication and targeting interventions so that the right patients receive the right interventions at the right time. Further research into the effectiveness and cost effectiveness of these services should factor in hidden costs, including those associated with managing the service.

Proposed variations of the stepped-wedge design can be used to accommodate multiple interventions

OBJECTIVES

Stepped-wedge design (SWD) cluster-randomized trials have traditionally been used for evaluating a single intervention. We aimed to explore design variants suitable for evaluating multiple interventions in an SWD trial.

STUDY DESIGN AND SETTING

We identified four specific variants of the traditional SWD that would allow two interventions to be conducted within a single cluster-randomized trial: concurrent, replacement, supplementation, and factorial SWDs. These variants were chosen to flexibly accommodate study characteristics that limit a one-size-fits-all approach for multiple interventions.

RESULTS

In the concurrent SWD, each cluster receives only one intervention, unlike the other variants. The replacement SWD supports two interventions that will not or cannot be used at the same time. The supplementation SWD is appropriate when the second intervention requires the presence of the first intervention, and the factorial SWD supports the evaluation of intervention interactions. The precision for estimating intervention effects varies across the four variants.

CONCLUSION

Selection of the appropriate design variant should be driven by the research question while considering the trade-off between the number of steps, number of clusters, restrictions for concurrent implementation of the interventions, lingering effects of each intervention, and precision of the intervention effect estimates.

Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective

Background

Health services that operate 7 days per week are under pressure to show the increased cost of providing weekend services can be measured in improved patient outcomes. The evidence for weekend allied health services in acute medical and surgical wards is weak and there is wide variation between the services offered at different hospitals.

Methods

This qualitative study was undertaken during a multi-site stepped wedge randomised controlled trial involving twelve acute medical and surgical wards from two Australian hospitals, in which weekend allied health services were removed before being reinstated with a stakeholder driven model. In-depth interviews were conducted with twenty-two staff responsible for managing weekend services at the involved hospitals. Participants were asked about their perceptions of the advantages and disadvantages of providing a weekend allied health service.

Results

Managers perceive the services improve patient flow and quality of care and reduce adverse incidents, such as falls and intensive care admissions. They also highlighted the challenges involved in planning, staffing and managing these services and the uncertainties about how to provide it most effectively.

Conclusions

Rising healthcare costs provide opportunity for public and professional debate about the most effective way of providing weekend allied health care services, particularly when health services provide limited other weekend services. Some managers perceived weekend allied health services to improve patient quality of care, but without studies which show these services on acute medical and surgical wards clearly change patient outcomes or provide health economic gains, these resources may need to be redirected. The resources may be better spent in areas with clear evidence to show the addition of weekend allied health services improves patient outcomes, such as on acute assess units and rehabilitation wards.

Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study

RATIONALE, AIMS AND OBJECTIVES

The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems.

METHODS

A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit.

RESULTS

An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01).

CONCLUSIONS

Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.

Early commencement of physical therapy in the acute phase following elective lower limb arthroplasty produces favorable outcomes: a systematic review and meta-analysis examining allied health service models

BACKGROUND

Temporal and dose-response relationships between allied health (AH) and recovery in the acute phase following lower limb (LL) arthroplasty are unclear. This systematic review investigates whether early commencement, additional therapy and/or weekend AH affects length of stay (LOS) and patient outcomes in the acute phase following LL arthroplasty.

METHODS

Electronic databases were searched in February 2015. Studies were included if they evaluated any of the following aspects of AH for adults following LL arthroplasty in the acute phase: Early compared to later therapy commencement; Additional therapy; or a 6- or 7-day service compared to a lesser service.

RESULTS

Twenty-four studies met the inclusion criteria, of which 19 investigated effects of physical therapy (PT) alone. Earlier PT reduced LOS (WMD = -1.23 days; 95% CI, -2.16 to -0.30) and resulted in higher probability of discharge directly home (relative risk = 1.45; 95% CI, 1.26-1.67). Addition of weekend PT reduced LOS (WMD = -1.04 days; 95% CI, -1.66 to -0.41) and improved function (SMD = 0.37; 95% CI, 0.02-0.73). Increasing PT from once to twice daily did not affect LOS (WMD = -0.35 days; 95% CI, -0.96-0.26) or function (SMD = 0.31; 95% CI, -0.06-0.71).

DISCUSSION

Early PT commencement and a weekend service may produce favorable outcomes following LL arthroplasty when baseline LOS is 4 days or more. Redistributing PT resources to commence as early as day of surgery regardless of weekday may accelerate postoperative recovery. Current, high quality research is needed to confirm these findings.

Experiences of Physical Therapists Working in the Acute Hospital Setting: Systematic Review

BACKGROUND

Physical therapists working in acute care hospitals require unique skills to adapt to the challenging environment and short patient length of stay. Previous literature has reported burnout of clinicians and difficulty with staff retention; however, no systematic reviews have investigated qualitative literature in the area.

PURPOSE

The purpose of this study was to investigate the experiences of physical therapists working in acute hospitals.

DATA SOURCES

Six databases (MEDLINE, CINAHL Plus, EMBASE, AMED, PsycINFO, and Sociological Abstracts) were searched up to and including September 30, 2015, using relevant terms.

STUDY SELECTION

Studies in English were selected if they included physical therapists working in an acute hospital setting, used qualitative methods, and contained themes or descriptive data relating to physical therapists' experiences.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction included the study authors and year, settings, participant characteristics, aims, and methods. Key themes, explanatory models/theories, and implications for policy and practice were extracted, and quality assessment was conducted. Thematic analysis was used to conduct qualitative synthesis.

RESULTS

Eight articles were included. Overall, study quality was high. Four main themes were identified describing factors that influence physical therapists' experience and clinical decision making: environmental/contextual factors, communication/relationships, the physical therapist as a person, and professional identity/role.

LIMITATIONS

Qualitative synthesis may be difficult to replicate. The majority of articles were from North America and Australia, limiting transferability of the findings.

CONCLUSIONS

The identified factors, which interact to influence the experiences of acute care physical therapists, should be considered by therapists and their managers to optimize the physical therapy role in acute care. Potential strategies include promotion of interprofessional and collegial relationships, clear delineation of the physical therapy role, multidisciplinary team member education, additional support staff, and innovative models of care to address funding and staff shortages.

Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

BACKGROUND

Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials.

METHODS

Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design.

RESULTS

This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used.

CONCLUSIONS

Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.

What Contributes to the Activeness of Ethnic Minority Patients with Chronic Illnesses Seeking Allied Health Services? A Cross-Sectional Study in Rural Western China

Actively seeking health services lies at the core of effective models of chronic disease self-management and contributes to promoting the utilization of allied health services (AHS). However, the use of AHS by ethnic minority Chinese, especially the elderly living in rural areas, has not received much attention. This study, therefore, aims to explore the association between personal characteristics and the activeness of ethnic minority patients with chronic diseases in rural areas of western China seeking AHS. A cross-sectional study was conducted to collect data on the socio-demographic and economic characteristics, health knowledge level and health communication channels of the sampled patients. A logistic regression model was used to examine the association of these predictors with the activeness of the surveyed patients in seeking AHS. A total of 1078 ethnic minorities over 45 years old who had chronic conditions were randomly selected from three western provinces in China and were interviewed in 2014. It is found that the New Cooperative Medical Scheme (NCMS) is the most salient predictor affecting the activeness of Chinese ethnic minorities in seeking AHS. The probability is 8.51 times greater for those insured with NCMS to actively seek AHS than those without (95% Confidence Interval (CI) 4.76–15.21; p < 0.001). Moreover, participants between 60 and 70 years old and those who have five to six household members are more likely to seek AHS compared with other social groups (Odds Ratio (OR) = 1.64, 95% CI 1.28–2.97, p = 0.007; OR = 1.95, 95% CI 1.15–2.36, p = 0.002). However, the activeness of patients seeking AHS is lower for those who have better household economic conditions. Besides socio-demographic predictors, the Chinese ethnic minorities’ activeness in seeking AHS is clearly associated with the communication channels used for receiving health information, which include direct communication with doctors (OR = 5.18, 95% CI 3.58–7.50, p < 0.001) and dissemination of elementary public health knowledge posted on bulletin boards (OR = 2.30, 95% CI 1.61–3.27, p < 0.001) and traditional mass media (OR = 1.74, 95% CI 1.22–2.48, p = 0.002). First, the government should further improve the coverage of NCMS to households suffering from chronic diseases and satisfy the requirements of social groups at different income levels and various ages in their health care to improve their activeness in AHS utilization. Second, doctors’ advice, bulletin boards and traditional media are common health communication channels for those seeking AHS and thus should be continuously employed in rural western China. Third, specified healthcare services should be designed to meet the needs of different patient segmentations.

Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior

PURPOSE

Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions.

MATERIALS AND METHODS

A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator.

RESULTS

Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture.

CONCLUSIONS

Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.