scholarly journals Review of implementation strategies to change healthcare provider behaviour in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (3) ◽  
pp. 453-460 ◽  
Author(s):  
Kerstin de Wit ◽  
Janet Curran ◽  
Brent Thoma ◽  
Shawn Dowling ◽  
Eddy Lang ◽  
...  
Keyword(s):  
Emergency Department ◽  
Implementation Research ◽  
Best Practice ◽  
Clinical Care ◽  
Intervention Strategy ◽  
Implementation Strategies ◽  
Evidence Based ◽  
Medicine Research ◽  
Canadian Association ◽  
New Evidence

AbstractObjectivesAdvances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.MethodsA systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.ResultsWe produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.ConclusionsWe present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Evidence-based guidelines for acute stabilization and management of neonates with persistent pulmonary hypertension of the newborn

2021 ◽  
Author(s):  
Molly K Ball ◽  
Ruth Seabrook ◽  
Elizabeth M Bonachea ◽  
Bernadette Chen ◽  
Omid Fathi ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Neonatal Intensive Care ◽  
Best Practice ◽  
Clinical Care ◽  
Persistent Pulmonary Hypertension ◽  
High Morbidity ◽  
Evidence Based ◽  
Extensive Literature ◽  
Disciplinary Expertise ◽  
Evidence Based Guidelines

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN.

scholarly journals Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity

2021 ◽  
Vol 2 ◽  
pp. 263348952110494
Author(s):  
Rachel C. Shelton ◽  
Prajakta Adsul ◽  
April Oh ◽  
Nathalie Moise ◽  
Derek M. Griffith
Keyword(s):  
Implementation Science ◽  
Health Equity ◽  
Implementation Research ◽  
Implementation Strategies ◽  
Health Inequities ◽  
Evidence Based ◽  
Racial Equity ◽  
Structural Racism ◽  
Core Elements ◽  
Evaluation Approaches

Background Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts. Methods Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations. Results We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration. Conclusion We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact. Plain language abstract There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.

Improving Oral Care in Patients Receiving Mechanical Ventilation

2005 ◽  
Vol 14 (5) ◽  
pp. 389-394 ◽  
Author(s):  
Constance J. Cutler ◽  
Nancy Davis
Keyword(s):  
Mechanical Ventilation ◽  
Best Practice ◽  
Current Practice ◽  
Oral Care ◽  
Implementation Strategies ◽  
Baseline Period ◽  
Evidence Based ◽  
Oral Secretions ◽  
Mucosal Tissues ◽  
Care Practices

• Background Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results. • Objectives To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care. • Methods This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward. • Results Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter. • Conclusions Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.

scholarly journals Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework

2021 ◽  
Vol 12 ◽  
Author(s):  
Rebecca J. Hood ◽  
Steven Maltby ◽  
Angela Keynes ◽  
Murielle G. Kluge ◽  
Eugene Nalivaiko ◽  
...  
Keyword(s):  
Virtual Reality ◽  
Best Practice ◽  
Healthcare Professionals ◽  
Clinical Care ◽  
Evidence Based ◽  
Stroke Management ◽  
Consultation Process ◽  
Stroke Treatment ◽  
Vr Training ◽  
Pilot Implementation

Delays in acute stroke treatment contribute to severe and negative impacts for patients and significant healthcare costs. Variability in clinical care is a contributor to delayed treatment, particularly in rural, regional and remote (RRR) areas. Targeted approaches to improve stroke workflow processes improve outcomes, but numerous challenges exist particularly in RRR settings. Virtual reality (VR) applications can provide immersive and engaging training and overcome some existing training barriers. We recently initiated the TACTICS trial, which is assessing a “package intervention” to support advanced CT imaging and streamlined stroke workflow training. As part of the educational component of the intervention we developed TACTICS VR, a novel VR-based training application to upskill healthcare professionals in optimal stroke workflow processes. In the current manuscript, we describe development of the TACTICS VR platform which includes the VR-based training application, a user-facing website and an automated back-end data analytics portal. TACTICS VR was developed via an extensive and structured scoping and consultation process, to ensure content was evidence-based, represented best-practice and is tailored for the target audience. Further, we report on pilot implementation in 7 Australian hospitals to assess the feasibility of workplace-based VR training. A total of 104 healthcare professionals completed TACTICS VR training. Users indicated a high level of usability, acceptability and utility of TACTICS VR, including aspects of hardware, software design, educational content, training feedback and implementation strategy. Further, users self-reported increased confidence in their ability to make improvements in stroke management after TACTICS VR training (post-training mean ± SD = 4.1 ± 0.6; pre-training = 3.6 ± 0.9; 1 = strongly disagree, 5 = strongly agree). Very few technical issues were identified, supporting the feasibility of this training approach. Thus, we propose that TACTICS VR is a fit-for-purpose, evidence-based training application for stroke workflow optimisation that can be readily deployed on-site in a clinical setting.

Abstract WP400: Simulation Training is a Feasible Implementation Strategy for Evidence Based Stroke Swallowing Screening

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Karen Stonecypher ◽  
Racquell Garrett ◽  
Barbara Kimmel ◽  
Stephanie Daniels ◽  
Jane Anderson
Keyword(s):  
Nursing Staff ◽  
Best Practice ◽  
Simulation Training ◽  
Quality Care ◽  
Video Clip ◽  
Implementation Strategies ◽  
Oral Intake ◽  
Evidence Based ◽  
Train The Trainer ◽  
Swallowing Screening

Backgroud and Purpose: A well-established best practice in providing safe, high quality care for patients with stroke is screening swallowing prior to oral intake. Effective implementation strategies are needed to support evidence based swallowing screening. The use of simulation is now being widely used to train healthcare professionals in evidence based practices. The purpose of this project was to assess the feasibility of simulation training modules (STMs) to support delivery of evidence based swallowing screening with frontline emergency department (ED) nurses. Methods: A train-the-trainer approach was used with (n=8) nurse champions who received didactic instruction and training with video clips and medical mannequins programmed to simulate auditory elements of stroke swallowing screening. After demonstration of mastery, each nurse champion then trained their peers using the same format. Feasibility for implementation of the STMs was evaluated through process mapping. Acquisition of skills was evaluated with a competency checklist and medical mannequins simulated with various stroke patient profiles. Knowledge was assessed using a pre/posttest. Results: A portable simulation lab was set up in the ED and nurse champions trained 100% of nursing staff over a two-month period. A total of 16 simulation sessions were needed to train all nursing staff (N=42). Didactic and video clip review was completed in 45-minute group sessions followed by 30-minute simulation practice sessions. Competency and knowledge was assessed 2-weeks after completing STMs. Competency checkoff sessions were completed in approximately 15-minutes. There was a significant increase in nurses’ knowledge and skills from baseline to posttest. Conclusions: It is feasible to implement STMs with frontline ED nurses. The STMs were beneficial for training and acquisition of skills in a controlled environment with a variety of patient examples. Repeated practice is critical to develop the auditory perceptual skills necessary for swallowing screening interpretation. STMs can be used in the ED for nurses to independently practice and improve swallowing screening skills.

scholarly journals Implementation of an Evidence-Based Care Pathway for Emergency Department Management of Sickle Cell Vaso-Occlusive Crisis Leads to Improved Clinical Outcomes

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4678-4678
Author(s):  
Jennifer Yui ◽  
Scott A. Peslak ◽  
David Lambert ◽  
Eric Russell ◽  
Farzana Sayani
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Hospital Admission ◽  
Sickle Cell ◽  
Clinical Pathway ◽  
Care Pathway ◽  
Clinical Care ◽  
Evidence Based ◽  
Opioid Dose ◽  
Clinical Care Pathway

BACKGROUND Painful vaso-occlusive crises (VOC) are the most common reason for acute care utilization in patients with sickle cell disease (SCD), and the emergency department (ED) is often the site of initial management and treatment. Treatment guidelines recommend initiation of analgesia with parenteral opioids within 30 minutes of presentation, timely reassessment of pain, and additional opioids as needed every 15-30 minutes. These targets are infrequently met, resulting in uncontrolled pain, increased likelihood of hospital admission, and deterioration of physician-patient relationships. METHODS We undertook a multidisciplinary effort to improve the management of VOC in the ED, by development and implementation of an evidence-based clinical care pathway. The clinical pathway was implemented at the Hospital of the University of Pennsylvania in December 2018, with direct education of hematology and ED providers around the content of the clinical pathway, and availability of the pathway on the institutional intranet. Specific areas of focus in the pathway included appropriate triaging of patients as emergency severity index 2, timely administration of initial opioid dose, rapid reassessment and administration of additional opioid doses as needed, as well as appropriate laboratory evaluation and evaluation for other common and/or serious complications of SCD. Outcome measures included time from ED registration to administration of first opioid dose, time between administration of first opioid dose and second opioid dose, and proportion of patients discharged from the ED. Balance measures included rate of ED readmission and length of stay. RESULTS There were 602 ED visits from 103 unique patients in the study period, with 256 visits in the six-month period prior to pathway implementation and 346 visits in the six-month period after implementation. Following pathway implementation, time from registration to first opioid dose fell from 114 minutes to 93 minutes (p = 0.003). The proportion of patients receiving their first opioid dose within 60 minutes of registration increased from 19% to 33%. Time from administration of the first opioid dose to the second opioid dose improved from 117 minutes to 94 minutes (p = 0.002). The proportion of patients receiving their second opioid dose within 60 minutes of the first opioid dose increased from 27% to 37%. There was no change in the rate of hospital admission from the ED, or in the proportion of patients who left without being seen (p = 0.710). There was also no change in rate of ED readmissions (p = 0.138) or length of stay (p = 0.483). CONCLUSION Implementation of an evidence-based clinical care pathway in the ED for SCD patients presenting with VOC led to significant improvement in outcomes, with decreased time to first opioid dose and decreased time from first to second opioid dose. Nevertheless, very few patients received guideline-based care, particularly with the goal of time to first opioid dose of less than 30 minutes. While our data demonstrate that provider education and clinical pathways clearly improve the management of VOC in the ED, additional interventions will be required to target other barriers to optimal management, including implicit biases, negative provider attitudes, and social stigma surrounding SCD. Disclosures No relevant conflicts of interest to declare.

scholarly journals Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study

2019 ◽  
Author(s):  
Alvaro Sanchez ◽  
Jose Ignacio Pijoan ◽  
Susana Pablo ◽  
Marta Maialen Mediavilla ◽  
Rita Sainz ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Primary Prevention ◽  
Clinical Care ◽  
Implementation Strategies ◽  
Research Field ◽  
Evidence Based ◽  
Policy Makers ◽  
Behavior Change Wheel ◽  
High Prevalence ◽  
Comprehensive Framework

Abstract Background: De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based and theory-informed process involving the main stakeholders (clinicians, managers, patients and researchers) for the design, deployment and assessment of de-implementation strategies for reducing low-value pharmacological prescribing.Methods: A Phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies – specifically, the Behavior Change Wheel (BCW) - will be conducted to design and model de-implementation strategies to favour reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients and researchers) in a collegiate way. Subsequently, a Phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians’ perspective, and patients’ experiences related to the clinical care received.Discussion: The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policy makers and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing.

scholarly journals Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

2018 ◽  
Vol 33 (5) ◽  
pp. 543-549 ◽  
Author(s):  
Saydia Razak ◽  
Sue Hignett ◽  
Jo Barnes
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Systems Approach ◽  
Clinical Care ◽  
Evidence Based ◽  
Key Factors ◽  
Publication Type ◽  
Organizational Policies ◽  
Response Planning ◽  
Explosive Events

AbstractIntroductionA Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.ProblemChallenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.MethodsA systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).ResultsSixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.DiscussionThis study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.Conclusion:The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.RazakS,HignettS,BarnesJ.Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review.Prehosp Disaster Med.2018;33(5):543–549.

scholarly journals Improving Management of Infantile Spasms by Adopting Implementation Science

2020 ◽  
Vol 51 (06) ◽  
pp. 377-388
Author(s):  
Debopam Samanta
Keyword(s):  
Health Care ◽  
Best Practice ◽  
Clinical Care ◽  
Infantile Spasms ◽  
Dissemination And Implementation ◽  
Evidence Based ◽  
Patient Centered ◽  
Practice Parameters ◽  
Health Care Structure ◽  
Evidence Based Guidelines

AbstractOver the last several decades, significant progress has been made in the discovery of appropriate therapy in the management of infantile spasms (IS). Based on several well-controlled studies, the American Academy of Neurology and the Child Neurology Society have published the current best practice parameters for the treatment of IS. However, dissemination and implementation of evidence-based guidelines remain a significant challenge. Though the number of well-performed controlled trials and systematic reviews is increasing exponentially, the proportion of valuable new information subsequently embedding into the routine clinical care is significantly lower. Planned and systematic implementation of evidence-based interventions in a given health care structure may outstrip the benefits of discovering a new insight, procedure, or drug in another controlled setting. Implementation problems can be broad-ranging to hinder effective, efficient, safe, timely, and patient-centered care without significant variation. The first part of this review article provides a detailed summary of some crucial comparative treatment studies of IS available in the literature. In the second part, practical challenges to mitigate the gap between knowledge and practice to improve outcomes in the management of IS has been explored, and a consolidated framework approach for systematic implementation research methodology has been discussed to implement evidence-based guidelines for the management of IS. Although large multicenter controlled studies will help gather quality evidence in the treatment of IS, a more comprehensive range of scientific methodologies, including qualitative research and mixed research methodologies, will hold the more considerable promise for implementing evidence-based practices in the health care system.

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