Expanding scope of Kirkpatrick model from training effectiveness review to evidence-informed prioritization management for cricothyroidotomy simulation

Modified Kirkpatrick model has been adopted to evaluate training effectiveness by 6 categories, including activity accounting (training objectives/success in organization change) at Level-0, reaction (satisfaction) at Level-1, learning (acquisition of surgical airway skills) at Level-2, behavior (post-training change in personal strengths) at Level-3, result (organizational or clinical outcomes) at Level-4, and Return on Investment (ROI) or Expectation (ROE) (monetary and societal values following training and other quality and safety related measures) at Level-5. The purpose of this hospital-based prospective observational study was twofold: i) To evaluate potential impacts on monetary and societal values and successful organization change following implementation of advanced Cricothyroidotomy simulator and standardized curriculum in healthcare simulation training, ii) To inform decisions of resource allocation by reviewing overall values and prioritization strategies for i) general surgeon/emergency physician ii) with seniority >5 years and iii) prior porcine training experience based on findings at Kirkpatrick Level-0, Level-4, and Level-5. Seventy doctors and 10 nurses completed Cricothyroidotomy training and follow-up questionnaires within 2021/22. All training usability scoring measured by Scales of Emergency Surgical Airway Simulator (SESAS-17) achieved over 4 out of 5 (Level-4) with effects in favor of emergency physicians or general surgeons (p < .5), regardless of seniority and prior training experience. Success in organization change (Level-0) and cost-effectiveness (Level-5) were hypothetically established using theoretical framework of Gleicher's formula and Roger's Diffusion of Innovation Theory. Overall training effectiveness, in terms of advantage in usability, cost-benefits and successful organizational changes, provided sound evidence to support continuous investment of new curriculum and innovative simulator and "Surgeon-and-emergency-physician-first" policy when it comes to resources allocation strategies for Cricothyroidotomy training. [ACGME competencies: Practice Based Learning and Improvement, Systems Based Practice.].

An unusual case of a penetrating neck injury (PNI) illustrating the use of a "no zone" approach for the management of this injury and a review of the literature

We present an unusual case of a young male with a penetrating neck injury (PNI) due to a work-related injury. A metallic foreign body traversed from entry at surgical Zone 2 to Zone 1 in the neck and resulted in a transection of the left thyrocervical trunk at the origin with the left subclavian artery. Computed Tomographic Angiography (CTA) of the aortic arch and major branch vessels demonstrated haemorrhage anterior to the left subclavian artery and left thyrocervical trunk. We describe some of the diagnostic and operative challenges which may occur in these rare and life-threatening injuries. We have also reviewed some of the recent key literature on this topic and have collated the recommendations of the review.

In recent years, there has been a movement away from selective “zone-based” mandatory surgical exploration for Zone 2 injuries, as well as invasive and time-consuming investigations (such as digital subtraction angiography, contrast oesophageal swallow and bronchoscopy) for Zone 1 and 3 injuries due to the high number of negative surgical procedures and investigations. We demonstrate there is now an evidence-based algorithm which demonstrates that a “no zone” approach to the management of these patients is safe and effective. This requires an initial physical examination looking for the presence or absence of “hard”, “soft” or “no” physical signs in these patients, and then deciding on subsequent management which would include immediate surgery, CTA of the aortic arch and branches (and subsequent surgical or other management) or observation only.

Our aim in describing this case it to highlight that there is now good evidence-based guidance for the safe and effective management of patients with this infrequent but potentially fatal injury.

Evidence-based management of the second stage of labor

The second stage of labor is defined as the time from complete dilation of the cervix to delivery of the fetus. The objective of this seminar is to provide a contemporary, evidence-based approach to management of the second stage of labor. This seminar reviews background maternal and fetal characteristics that impact the duration of the second stage of labor, the recommended evidence-based management (e.g. immediate pushing, manual rotation, operative vaginal delivery), and the maternal/neonatal morbidity clinicians must consider when deciding between operative delivery and a prolonged second stage of labor.

The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society

Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.

Barriers, Facilitators, Process and Sources of Evidence for Evidence-Based Management among Health Care Managers: A Qualitative Systematic Review

Background

Evidence-based management (EBMgt) improves managerial decisions as a bridge from theory to practice. For reason that it has a critical impact on organization performance. The purpose of this study was to identify factors affecting EBMgt among managers.

Methods

The following electronic databases were used: PubMed, Web of Science, Cochrane, ProQuest, Embase and Scopus. In addition, we searched Google Scholar, Emerald, Academy of Management (AOM), and the website for the Center for Evidence-Based Management (CEBMa) for articles related to EBMgt. We used data sources published up to September 2017, without language restriction. We appraised the methodological quality of studies using the checklists of SRQR and MMAT. The synthesis involved interpretative analysis based on the principles of meta-synthesis.

Results

Of 26,011 identified studies, 26 met the full inclusion criteria. Of the 26 studies assessed, the frequency of qualitative studies and mixed-methods were 20 and 6, respectively, and the quality of 3 studies was weak. A total of 23 studies from 7 countries were included: Canada (n=8), USA (n=6), Australia (n=4), UK (n=3), Iran (n=1, Brazil (n=1); none were from Africa. Meta-synthesis findings of 23 studies identified four main factors: facilitators (5 main themes), barriers (5 main themes), sources of evidence (4 main themes), and the process of decision making in EBMgt (1 main theme).

Conclusions

EBMgt is crucial to improve the quality of management decisions, and hence, to improve service delivery, effectiveness and efficiency. Furthermore, to increase the benefit and utilization of EBMgt, training organizations and research institutes must more actively involve managers in setting research plans.

How practitioners integrate decision triggers with existing metrics in conservation monitoring

Decision triggers are defined thresholds in the status of monitored variables that indicate when to undertake management, and avoid undesirable ecosystem change. Decision triggers are frequently recommended to conservation practitioners as a tool to facilitate evidence-based management practices, but there has been limited attention paid to how practitioners are integrating decision triggers into existing monitoring programs. We sought to understand whether conservation practitioners' use of decision triggers was influenced by the type of variables in their monitoring programs. We investigated this question using a practitioner-focused workshop involving a structured discussion and review of eight monitoring programs. Among our case studies, direct measures of biodiversity (e.g. native species) were more commonly monitored, but less likely to be linked to decision triggers (10% with triggers) than measures being used as surrogates (54% with triggers) for program objectives. This was because decision triggers were associated with management of threatening processes, which were often monitored as a surrogate for a biodiversity asset of interest. By contrast, direct measures of biodiversity were more commonly associated with informal decision processes that led to activities such as management reviews or external consultation. Workshop participants were in favor of including more formalized decision triggers in their programs, but were limited by incomplete ecological knowledge, lack of appropriately skilled staff, funding constraints, and/or uncertainty regarding intervention effectiveness. We recommend that practitioners consider including decision triggers for discussion activities (such as external consultation) in their programs as more than just early warning points for future interventions, particularly for direct measures. Decision triggers for discussions should be recognized as a critical feature of monitoring programs where information and operational limitations inhibit the use of decision triggers for interventions.

An Evidence-Based Framework for Evidence-Based Management in Healthcare Organizations: A Delphi Study

Background

Evidence-based management (EBMgt) is a growing literature concept in management sciences which claims that management decision-making must be based on the best available evidence. The aim of this paper is to present and provide an evidence-based framework for EBMgt to improve decision-making in healthcare organizations.

Methods

A two-round Delphi survey was used to collect the factors affecting EBMgt. Purposive and snowball sampling methods were used in both rounds. In round 1, we conducted a systematic review and a series of semi-structured interviews (n=45). In round 2, a specific questionnaire with four main parts was designed. The experts (n=21) were asked to rate on a 9-point Likert scale the importance of each factor. The data was collected through Google Forms (n=11) and paper forms (n=10).

Results

Participants were mostly men (73%). Overall, 126 factors were selected in round 1. Factors were classified into 4 categories: facilitators, barriers, the sources of evidence and EBMgt process that consisted of 48, 46, 22 and 10 factors, respectively. In round 2, based on median scores, many factors (n=114) were found to be very important. Only, 12 factors have a median score of less than 3 and were excluded from the study. Finally, 114 factors were confirmed.

Conclusions

Confirmed factors played significant roles in affecting the practice of EBMgt among healthcare managers. We tried to facilitate interaction between these factors in the framework. Depending on the type of problem, using six steps of EBMgt process, managers will select the best evidence among six sources of evidence.

Evidence-based management - healthcare manager viewpoints

Purpose Hospital manager decisions can have a significant impact on service effectiveness and hospital success, so using an evidence-based approach can improve hospital management. The purpose of this paper is to identify evidence-based management (EBMgt) components and challenges. Consequently, the authors provide an improving evidence-based decision-making framework. Design/methodology/approach A total of 45 semi-structured interviews were conducted in 2016. The authors also established three focus group discussions with health service managers. Data analysis followed deductive qualitative analysis guidelines. Findings Four basic themes emerged from the interviews, including EBMgt evidence sources (including sub-themes: scientific and research evidence, facts and information, political-social development plans, managers' professional expertise and ethical-moral evidence); predictors (sub-themes: stakeholder values and expectations, functional behavior, knowledge, key competencies and skill, evidence sources, evidence levels, uses and benefits and government programs); EBMgt barriers (sub-themes: managers' personal characteristics, decision-making environment, training and research system and organizational issues); and evidence-based hospital management processes (sub-themes: asking, acquiring, appraising, aggregating, applying and assessing). Originality/value Findings suggest that most participants have positive EBMgt attitudes. A full evidence-based hospital manager is a person who uses all evidence sources in a six-step decision-making process. EBMgt frameworks are a good tool to manage healthcare organizations. The authors found factors affecting hospital EBMgt and identified six evidence sources that healthcare managers can use in evidence-based decision-making processes.

Use of evidence-based management in healthcare administration decision-making

Purpose The purpose of this paper is to examine whether healthcare leaders use evidence-based management (EBMgt) when facing major decisions and what types of evidence healthcare administrators consult during their decision-making. This study also intends to identify any relationship that might exist among adoption of EBMgt in healthcare management, attitudes towards EBMgt, demographic characteristics and organizational characteristics. Design/methodology/approach A cross-sectional study was conducted among US healthcare leaders. Spearman's correlation and logistic regression were performed using the Statistical Package for the Social Sciences (SPSS) 23.0. Findings One hundred and fifty-four healthcare leaders completed the survey. The study results indicated that 90 per cent of the participants self-reported having used an EBMgt approach for decision-making. Professional experiences (87 per cent), organizational data (84 per cent) and stakeholders' values (63 per cent) were the top three types of evidence consulted daily and weekly for decision-making. Case study (75 per cent) and scientific research findings (75 per cent) were the top two types of evidence consulted monthly or less than once a month. An exploratory, stepwise logistic regression model correctly classified 75.3 per cent of all observations for a dichotomous "use of EBMgt" response variable using three independent variables: attitude towards EBMgt, number of employees in the organization and the job position. Spearman's correlation indicated statistically significant relationships between healthcare leaders' use of EBMgt and healthcare organization bed size ( r_s = 0.217, n = 152, p < 0.01), attitude towards EBMgt ( r_s = 0.517, n = 152, p < 0.01), and the number of organization employees ( r_s = 0.195, n = 152, p = 0.016). Originality/value This study generated new research findings on the practice of EBMgt in US healthcare administration decision-making.

Health Care Managers' Perspectives on the Sources of Evidence in Evidence-Based Hospital Management: A Qualitative Study in Iran

BACKGROUND

Evidence-based management (EBMgt) has been developed as a management framework for improving the quality of management decisions. To use that, we need to identify the source of evidence in decision-making. Therefore, the purpose of this study was to identify the sources of evidence in managing hospitals.

METHODS

Qualitative methods were used to explore the sources of evidence and to identify hospital managers' attitudes towards evidence-based management. A series of semi-structured interviews (n=48), with a purposive sample of 48 participants, were conducted in 2016. Also, four focus group discussions (FGDs) were conducted with health managers and specialists in the field of management. A questionnaire was used for collection of demographic characteristics and managers' perspectives.

RESULTS

Six main themes emerged from the interviews including: scientific and research evidence, facts and information of hospital, political-social development plans, managers' professional expertise and ethical-moral evidence. Also, the results showed that the majority of participants believed to use the evidence-based hospital management (95.83%).

CONCLUSIONS

Our study suggested that a full evidence-based hospital manager someone who is using all the sources of evidence for making hospital decisions. Using hexagon of evidence sources, managers can identify the best available evidence for hospital decisions and to make the best decision in the process of evidence-based decision making.

Towards quantitative condition assessment of biodiversity outcomes: Insights from Australian marine protected areas

Protected area management effectiveness (PAME) evaluation is increasingly undertaken to evaluate governance, assess conservation outcomes and inform evidence-based management of protected areas (PAs). Within PAME, quantitative approaches to assess biodiversity outcomes are now emerging, where biological monitoring data are directly assessed against quantitative (numerically defined) condition categories (termed quantitative condition assessments). However, more commonly qualitative condition assessments are employed in PAME, which use descriptive condition categories and are evaluated largely with expert judgement that can be subject to a range of biases, such as linguistic uncertainty and overconfidence. Despite the benefits of increased transparency and repeatability of evaluations, quantitative condition assessments are rarely used in PAME. To understand why, we interviewed practitioners from all Australian marine protected area (MPA) networks, which have access to long-term biological monitoring data and are developing or conducting PAME evaluations. Our research revealed that there is a desire within management agencies to implement quantitative condition assessment of biodiversity outcomes in Australian MPAs. However, practitioners report many challenges in transitioning from undertaking qualitative to quantitative condition assessments of biodiversity outcomes, which are hampering progress. Challenges include a lack of agency capacity (staff numbers and money), knowledge gaps, and diminishing public and political support for PAs. We point to opportunities to target strategies that will assist agencies overcome these challenges, including new decision support tools, approaches to better finance conservation efforts, and to promote more management relevant science. While a single solution is unlikely to achieve full evidence-based conservation, we suggest ways for agencies to target strategies and advance PAME evaluations toward best practice.

Questionnaire-based survey in a developing country showing noncompliance with paediatric gastro-oesophageal reflux practice guidelines

AIM

This 2015 study investigated whether Lebanese paediatricians diagnosed and managed gastro-oesophageal reflux disease (GERD) in infants and children in accordance with the 2009 guidelines from the North American and European Societies for Paediatric Gastroenterology, Hepatology and Nutrition.

METHODS

Paediatricians members of the Lebanese Order of Physicians with updated email addresses were invited to complete a web-based survey between September and November 2015, to assess their knowledge and management of GERD.

RESULTS

Responses were received from 114 of the 543 paediatricians, and 96 were analysed. Only two respondents complied fully with the international guidelines. The majority diagnosed GERD in infants based solely on their medical history and examination. Moreover, nearly two-thirds of the respondents would start an empiric trial with acid suppression. Around half of the respondents considered proton pump inhibitors to be the mainstay of GERD treatment.

CONCLUSION

This was the first Lebanese study that surveyed the management of paediatric GERD. Only 2.1% of the paediatricians followed the guidelines on the evidence-based management of GERD. This highlights the need for studies to assess barriers to guideline implementation and the development of new guidelines accounting for regional factors, mainly the cost of investigations and prevalence of medical insurance.

An international comparison of the management of the neck in early oral squamous cell carcinoma in the Netherlands, UK, and USA

BACKGROUND

Early oral cavity squamous cell carcinoma (OCSCC) management appears to vary both within and between countries. Variation in practice can be an indicator of absence of evidence-based management and may negatively influence survival and morbidity. The exact variation and the relationship to differences in guidelines are unknown. This study aimed to report on these variations in the Netherlands, UK, and USA, and to evaluate them.

METHODS

Information regarding the variation in OCSCC management strategies was obtained from a questionnaire sent to representatives of head and neck cancer centers in the Netherlands, UK, and USA. Within-country and between-country variations were also assessed in light of the different guidelines.

RESULTS

In total, representatives of 45 centers completed the questionnaire; 10 from the Netherlands, 26 from the UK and 9 from the USA. Our results demonstrate a distinct variation in the diagnoses, treatment and follow-up of OCSCC, both within and between countries. Only a small amount of variation between countries could be linked to differences in guidelines.

CONCLUSIONS

There is high variation in the management of the neck in OCSCC. There seem to be a need for direct evidence about optimal management decisions to establish more evidence-based management and uniform practice.

Trauma in the geriatric population

Injury in older adults is a looming public health crisis. This article provides a broad overview of geriatric trauma across the continuum of care. After a review of the epidemiology of geriatric trauma, optimal approaches to patient care are presented for triage and transport, trauma team activation and initial assessment, inpatient management, and injury prevention. Special emphasis is given to assessment of frailty, advanced care planning, and transitions of care.

Are we missing the boat? Current uses of long-term biological monitoring data in the evaluation and management of marine protected areas

Protected area management agencies are increasingly using management effectiveness evaluation (MEE) to better understand, learn from and improve conservation efforts around the globe. Outcome assessment is the final stage of MEE, where conservation outcomes are measured to determine whether management objectives are being achieved. When quantitative monitoring data are available, best-practice examples of outcome assessments demonstrate that data should be assessed against quantitative condition categories. Such assessments enable more transparent and repeatable integration of monitoring data into MEE, which can promote evidence-based management and improve public accountability and reporting. We interviewed key informants from marine protected area (MPA) management agencies to investigate how scientific data sources, especially long-term biological monitoring data, are currently informing conservation management. Our study revealed that even when long-term monitoring results are available, management agencies are not using them for quantitative condition assessment in MEE. Instead, many agencies conduct qualitative condition assessments, where monitoring results are interpreted using expert judgment only. Whilst we found substantial evidence for the use of long-term monitoring data in the evidence-based management of MPAs, MEE is rarely the sole mechanism that facilitates the knowledge transfer of scientific evidence to management action. This suggests that the first goal of MEE (to enable environmental accountability and reporting) is being achieved, but the second and arguably more important goal of facilitating evidence-based management is not. Given that many MEE approaches are in their infancy, recommendations are made to assist management agencies realize the full potential of long-term quantitative monitoring data for protected area evaluation and evidence-based management.

Neonatal surgery: towards evidence-based practice and management

Like all modern medical therapy, neonatal surgery is founded on clinical research, well-tried clinical practice and basic scientific research. Likewise, modern neonatal surgery strives increasingly for evidence-based management and practice. The very nature of neonatal and pediatric surgery renders associated research challenging because of the rarity and small numbers of surgical disorders and varying resources in different countries and institutions and consequently only a few well-designed trials on truly important issues in neonatal surgical treatment have been performed. This article highlights the research methods by which valid evidence-based research data is obtained in observational studies, randomized controlled trials, and meta-analyses. The problem of small numbers of patients may be overcome by multi-center trials, meta-analyses, and networking. Consideration is also given on the quality and the validity of the study data as well as ethical issues in neonatal surgical research.

Assessing the impact of human trampling on vegetation: a systematic review and meta-analysis of experimental evidence

Vegetation trampling resulting from recreation can adversely impact natural habitats, leading to the loss of vegetation and the degradation of plant communities. A considerable primary literature exists on this topic, therefore it is important to assess whether this accumulated evidence can be used to reach general conclusions concerning vegetation vulnerability to inform conservation management decisions. Experimental trampling studies on a global scale were retrieved using a systematic review methodology and synthesised using random effects meta-analysis. The relationships between vegetation recovery and each of initial vegetation resistance, trampling intensity, time for recovery, Raunkiaer life-form (perennating bud position), and habitat were tested using random effects multiple meta-regressions and subgroup analyses. The systematic search yielded 304 studies; of these, nine reported relevant randomized controlled experiments, providing 188 vegetation recovery effect sizes for analysis. The synthesis indicated there was significant heterogeneity in the impact of trampling on vegetation recovery. This was related to resistance and recovery time, and the interactions of these variables with Raunkiaer life-form, but was not strongly dependent on the intensity of the trampling experienced. The available evidence suggests that vegetation dominated by hemicryptophytes and geophytes recovers from trampling to a greater extent than vegetation dominated by other life-forms. Variation in effect within the chamaephyte, hemicryptophyte and geophyte life-form sub-groups was also explained by the initial resistance of vegetation to trampling, but not by trampling intensity. Intrinsic properties of plant communities appear to be the most important factors determining the response of vegetation to trampling disturbance. Specifically, the dominant Raunkiaer life-form of a plant community accounts for more variation in the resilience of communities to trampling than the intensity of the trampling experienced, suggesting that simple assessments based on this trait could guide decisions concerning sustainable access to natural areas. Methodological and reporting limitations must be overcome before more disparate types of evidence can be synthesised; this would enable more reliable extrapolation to non-study situations, and a more comprehensive understanding of how assessments of intrinsic plant traits can be used to underpin conservation management decisions concerning access.

The meaning of evidence-based management to Brazilian senior nurse leaders

PURPOSE

The study objective was to understand the meaning of evidence-based management for senior nurse leaders in accredited, public hospitals in the State of Sao Paulo, Brazil.

DESIGN AND METHOD

A phenomenological approach was used to analyze interviews conducted with 10 senior nurse leaders between August 2011 and March 2012. The analytic method was developed by the Brazilian phenomenologist, Martins.

FINDINGS

Senior nurse leaders described how they critically appraise many sources of evidence when making managerial decisions. They emphasized the importance of working with their teams to locally adapt and evaluate best evidence associated with managerial decision making and organizational innovations. Their statements also demonstrated how they use evidence-based management to support the adoption of evidence-based practices. They did not, however, provide specific strategies for seeking out and obtaining evidence. Notable challenges were traditional cultures and rigid bureaucracies, while major facilitators included accreditation, teamwork, and shared decision making.

CONCLUSIONS

Evidence-based management necessitates a continuous process of locating, implementing, and evaluating evidence. In this study leaders provided multiple, concrete examples of all these processes except seeking out and locating evidence. They also gave examples of other leadership skills associated with successful adoption of evidence-based practice and management, particularly interdisciplinary teamwork and shared decision making.

CLINICAL RELEVANCE

This study demonstrates senior nurse leaders' awareness and utilization of evidence-based management. The study also suggests what aspects of evidence-based management need further development, such as more active identification of potential, new organizational innovations.