Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial

Background

The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.

Methods/design

The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle.

The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital.

Discussion

Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.

Trial registration

Australia New Zealand Clinical Trial Registry ACTRN12615000325505

The iPROMOS protocol: a stepped-wedge study to implement routine patient-reported outcomes in a medical oncology outpatient setting

INTRODUCTION

Patient-reported outcome measures (PROMs) are data capture tools that collect information directly from patients. Several large research studies provide evidence that the use of PROMs in routine care provides benefits to mortality and morbidity outcomes in medical oncology patients. Despite this, implementation of PROMs in daily clinical routine is slow and challenging.

METHODS AND ANALYSIS

This study will use a stepped-wedge design to assess the implementation of a PROM intervention in highly frequented medical oncology outpatient clinics. During a lead-in period of 4 weeks, control data will be collected. The intervention will then be implemented for 4 weeks in Clinic 1 initially, then in Clinic 2 for another 4 weeks. 500 patient encounters will be measured over the 12 weeks in total. The process of implementation will be informed and evaluated using the Medical Research Council Guidelines for Implementing Complex Interventions. The study will be guided by the Promoting Action Research in Health Services framework approach for implementation. The intervention and implementation outcomes will be measured using qualitative and quantitative data.

ETHICS AND DISSEMINATION

Ethical approval has been obtained, approval number HREC/16/QRBW/100 by the Royal Brisbane and Women's Hospital Human Research Ethics Committee. Results will be disseminated in peer-reviewed journals and at scientific meetings.

TRIAL REGISTRATION

ACTRN12618000398202. Trial Status: Opened on 25 March 2018 and will continue until 12 months after the last PROMs reporting encounter.

Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations

The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision-making (SDM)-based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy-based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO-OP) to treat survivors of stroke. At the end of the 4-month CO-OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO-OP site champions. A semi-structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio-recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO-OP implementation were extracted and co-constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context-specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem-solving within the relevant practice context.

Factors in Randomized Controlled Trials Reported to Impact the Implementation of Patient-Reported Outcome Measures Into Routine Care: Protocol for a Systematic Review

Background

Patient-reported outcome measures (PROMs) are tools that enable patients to directly report their own assessments of well-being, or symptoms, in a structured and consistent way. Despite the usefulness of PROMs in optimizing health outcomes, their use in clinical practice is not routine. PROMs are complex to integrate into the clinical setting, with many elements potentially impacting on the success of implementation. For this reason, a protocol has been developed to guide a systematic review to collate information on implementation as presented in the randomized controlled trials (RCTs) to date.

Objective

The primary objective of this systematic review is to identify and synthesize factors available from RCT data about the fidelity of PROM interventions in clinical practice. The secondary objective will be an assessment of how implementation factors impact fidelity outcomes.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards will be followed. MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature via OvidSP will be accessed using a defined search strategy. Grey literature and ClinicalTrials.gov will be reviewed for unpublished studies. Data extraction will be done to identify fidelity and factors impacting implementation, summarized using a narrative synthesis. An evidence-based implementation science framework will assist in identifying potential elements of importance and their effect on the process and outcomes of implementation. A meta-analysis to assess the impact of implementation factors will be attempted. A Cochrane risk of bias tool will be used.

Results

This protocol has received funding, and searches of databases will commence at the end of May 2019. It is planned that this systematic review will be finalized for publication in (December) 2019.

Conclusions

Applying an implementation science evidence-based framework to the published literature may identify factors present in the data that impact on the implementation of PROMs into routine clinical care. This systematic review aims to improve understanding of how these factors impact the fidelity of this intervention, so that PROMs can be more effectively used in the care of patients. This systematic review can also offer more detailed information about the process and outcomes of successful implementation of PROMs.

International Registered Report Identifier (IRRID)

PRR1-10.2196/14579

Statistical process control assessed implementation fidelity of patient-reported outcome measures (PROMs) in routine care

OBJECTIVES

Ensuring implementation fidelity of patient-reported outcome measures (PROMs) in the complex clinical setting remains exigent. We aimed to integrate the routine use of PROM reports in day-to-day patient care and assess the implementation outcomes using statistical process control (SPC) methods.

STUDY DESIGN AND SETTING

This prospective pilot study used an implementation science framework to integrate PROMs. SPC analysis was applied to track patient completion rates and staff acknowledgment rates over time. Daily observational data across clinical areas were collected to assess potential variations.

RESULTS

Data were available from 324 patient encounters over 14 weeks. On average, 78% (52% to 100%) of eligible patients entering the clinic completed the PROMs; staff acknowledged 78% (50-100%) of these patient reports. Most patterns of fluctuation were inside the control frame. Dips in compliance relating to changes in clinic daily routine, including the introduction of the second randomized clinic, were quickly resolved with a structured response.

CONCLUSION

Implementation of PROMs was feasible with reasonable patient completion and staff acknowledgment rates. Fidelity was vulnerable to barriers impacting the daily routine or unusual events in the clinics, suggesting that greater standardization and integration into clinic processes may yet further improve compliance and consistency of reporting.

Supporting care home residents in the last year of life through 'Needs Rounds': Development of a pre-implementation programme theory through a rapid collaborative online approach

Background

Realist evaluation aims to address the knowledge to practice gap by explaining how an intervention is expected to work, as well as what is likely to impact upon the success of its implementation, by developing programme theories that link contexts, mechanisms and outcomes. Co-production approaches to the development of programme theories offer substantial benefits in addressing power relations, including and valuing different types of knowledge, and promoting buy-in from stakeholders while navigating the complex social systems in which innovations are embedded. This paper describes the co-production of an initial programme theory of how an evidence based intervention developed in Australia - called 'Palliative Care Needs Rounds' - might work in England and Scotland to support care home residents approaching their end of life.

Methods

Using realist evaluation and iPARIHS (integrated Promoting Action on Research Implementation in Health Services) we sought to determine how contexts and mechanisms of change might shape implementation outcomes. Pre-intervention online interviews (n = 28) were conducted (February-April 2021), followed by four co-design online workshops with 43 participants (April-June 2021). The online interviews and workshops included a range of stakeholders, including care home staff, specialist palliative care staff, paramedics, general practitioners, and relatives of people living in care homes.

Results

This methodology paper reports developments in realist evaluation and co-production methodologies, and how they were used to develop context, mechanisms, outcomes (CMOs) configurations, and chains of inference. The initial (pre-intervention) programme theory is used to illustrate this process. Two developments to iPARIHS are described. First, involving stakeholders in the collaborative co-design workshops created opportunities to commence facilitation. Second, we describe developing iPARIHS' innovation component, to include novel stakeholder interpretations, perceptions and anticipated use of the intervention as they participated in workshop discussions.

Conclusions

This rapid and robust co-production methodology draws on interactive collaborative research practices (interviews, workshop discussions of data, illustrative vignettes and visual methods). These innovative and engaging methods can be packaged for online processes to develop, describe and interrogate the CMOs in order to co-produce a programme theory. These approaches also commence facilitation and innovation, and can be adopted in other implementation science and realist studies.

Implementation of Patient-Reported Outcomes in a Medical Oncology Setting (the iPROMOS Study): Type II Hybrid Implementation Study

BACKGROUND

Clinical trials have demonstrated that patient-reported outcome measures (PROMs) can improve mortality and morbidity outcomes when used in clinical practice.

OBJECTIVE

This study aimed to prospectively investigate the implementation of PROMs in routine oncology. Outcomes measured included improved symptom detection, clinical response to symptom information, and health service outcomes.

METHODS

Two of 12 eligible clinics were randomized to implement symptom PROMs in a medical oncology outpatient department in Australia. Randomization was carried out at the clinic level. Patients in control clinics continued with usual care; those in intervention clinics completed a symptom PROM at presentation. This was a pilot study investigating symptom detection, using binary logistic models, and clinical response to PROMs investigated using multiple regression models.

RESULTS

A total of 461 patient encounters were included, consisting of 242 encounters in the control and 222 in the intervention condition. Patients in these clinics most commonly had head and neck, lung, prostate, breast, or colorectal cancer and were seen in the clinic for surveillance and oral or systemic treatments for curative, metastatic, or palliative cancer care pathways. Compared with control encounters, the proportion of symptoms detected increased in intervention encounters (odds ratio 1.05, 95% CI 0.99-1.11; P=.08). The odds of receiving supportive care, demonstrated by nonroutine allied health review, increased in the intervention compared with control encounters (odds ratio 3.54, 95% CI 1.26-9.90; P=.02).

CONCLUSIONS

Implementation of PROMs in routine care did not significantly improve symptom detection but increased the likelihood of nonroutine allied health reviews for supportive care. Larger studies are needed to investigate health service outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000398202; https://tinyurl.com/3cxbemy4.

Implementing evidence-based practices in rural settings: a scoping review of theories, models, and frameworks

Background

Rural healthcare has unique characteristics that affect the dissemination and implementation of evidence-based interventions. Numerous theories, models, and frameworks have been developed to guide implementation of healthcare interventions, though not specific to rural healthcare. The present scoping review sought to identify the theories, models, and frameworks most frequently applied to rural health and propose an approach to rural health research that harnesses selected constructs from these theories, models, and frameworks. This resulting synthesis can serve as a guide to researchers, policy makers, and clinicians seeking to employ commonly used theories, models, and frameworks to rural health.

Methods

We used the Scopus abstract indexing service to identify peer-reviewed literature citing one or more of theories, models, or frameworks used in dissemination and implementation research and including the word "rural" in the Title, Abstract, or Keywords. We screened the remaining titles and abstracts to ensure articles met additional inclusion criteria. We conducted a full review of the resulting 172 articles to ensure they identified one or more discrete theory, model, or framework applied to research or quality improvement projects. We extracted the theories, models, and frameworks and categorized these as process models, determinant frameworks, classic theories, or evaluation frameworks.

Results

We retained 61 articles of which 28 used RE-AIM, 11 used Community-Based Participatory Research (CBPR) framework, eight used the Consolidated Framework for Implementation Research (CFIR), and six used the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS). Additional theories, models, and frameworks were cited in three or fewer reports in the literature. The 14 theories, models, and frameworks cited in the literature were categorized as seven process models, four determinant frameworks, one evaluation framework, and one classic theory.

Conclusions

The RE-AIM framework was the most frequently cited framework in the rural health literature, followed by CBPR, CFIR, and iPARIHS. A notable advantage of RE-AIM in rural healthcare settings is the focus on reach as a specified outcome, given the challenges of engaging a geographically diffuse and often isolated population. We present a rationale for combining the strengths of these theories, models, and frameworks to guide a research agenda specific to rural healthcare research.

Systematic Review Registration

https://osf.io/fn2cd/.