Clinicians’ delirium treatment practice, practice change, and influences: A national online survey

Background: Recent studies cast doubt on the net effect of antipsychotics for delirium. Aim: To investigate the influence of these studies and other factors on clinicians’ delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework. Design: Australia-wide online survey of relevant clinicians. Setting/participants: Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals’ organisations. Results: Most of the sample ( n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents’ delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001). Conclusion: Clinicians’ use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.

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Off-label drugs in palliative care: a Group Delphi treatment recommendation process

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2019-002165 ◽

2020 ◽

pp. bmjspcare-2019-002165

Author(s):

Constanze Remi ◽

Kathrin Weingärtner ◽

Vera Hagemann ◽

Claudia Bausewein ◽

Farina Hodiamont

Keyword(s):

Palliative Care ◽

Patient Safety ◽

Online Survey ◽

Delphi Process ◽

Treatment Quality ◽

Direct Patient Care ◽

Treatment Recommendation ◽

Off Label Use ◽

Off Label ◽

Label Use

ObjectivesThe use of drugs beyond their marketing authorisation, that is, off-label use, is common practice in palliative care with over 70% of off-label use having little or no scientific support. The lack of evidence makes recommendations for off-label use essential, in order to increase the safety of drug therapy and thus patient safety. The aim of this study was to develop a guide for preparing and consenting drug-specific recommendations for off-label use in palliative care.MethodsGroup Delphi Study with three rounds and a prior online survey to identify topics of dissent. Participants represented professional groups working in palliative care involved in direct patient care and/or drug management and various care settings. Furthermore, representatives of relevant professional associations, experts with academic, non-clinical background and experts with international expertise were invited.Results18/20 invited professionals participated in the prior online-survey. 15 experts participated in the Group Delphi process. Six domains, including identification of drugs, drug uses, assessment of evidence, formulation, consensus and updating of recommendations were generated and respective statements were included in the Group Delphi process. The consensus process resulted in 28 statements forming the guide for recommendations.ConclusionsThe resultant systematic approach for preparing and consenting drug-specific recommendations for off-label use will allow the development of recommendations with transparent and reproducible monographs. This will help to increase treatment quality and patient safety as well as security of decision-making in palliative care. The developed guide is part of a larger project aiming to provide therapy recommendations for areas that have little or no scientific evidence.

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Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery.

10.21203/rs.3.rs-40581/v3 ◽

2020 ◽

Author(s):

Annemarie De Leo ◽

Sara BAYES ◽

Dianne BLOXSOME ◽

Janice BUTT

Keyword(s):

Evidence Based Practice ◽

Theoretical Domains Framework ◽

Practice Change ◽

Evidence Based ◽

Valuable Insight ◽

Implementation Processes ◽

Change Factors ◽

Change Projects ◽

Formed Part ◽

Ebp Implementation

Abstract Background Despite the advancement of scientific research in the field of maternity care, midwives face challenges translating latest evidence into evidence-based practice (EBP) and express reticence towards leading practice change in clinical areas. This study aimed to explore midwifery leaders’ views on what factors help or hinder midwives’ efforts to translate latest evidence into everyday practice and consider them in relation to both the Capability, Opportunity, Motivation and Behaviour (COM-B) model and Theoretical Domains Framework (TDF).Methods This qualitative study formed part of a larger Action Research (AR) project that was designed to improve midwives’ EBP implementation capability. Data were obtained from eight Western Australian midwifery leaders who were employed in either managerial or executive positions within their organisation. Five midwives attended a focus group workshop and three opted for face-to-face interviews. Thematic analysis was used to code the transcribed data and group alike findings into sub-categories, which were collapsed to four major categories and one overarching core finding. These were mapped to a matrix combining the COM-B and TDF to establish the usability of these tools in midwifery contexts. Results Four major categories were developed from the data collected in this study. Three reported the hindrances midwives’ experienced when trying to initiate new EBPs: “For midwives, medical opposition and workplace culture are the biggest challenges”, “Fear can stop change: it’s personal for midwives” and “Midwives are tired of fighting the battle for EBP; they need knowledge and the confidence to bring about practice change.” The other major category highlighted factors midwives’ considered helpers of EBP: “Having stakeholder buy-in and strong midwifery leadership is a huge advantage.” When mapped to the TDF and COM-B, these findings provided valuable insight into the helpers of and hindrances to evidence-based practice in midwifery. Conclusion Midwives are motivated to initiate evidence-based change yet have limited knowledge of implementation processes or the confidence to lead practice change. Factors such as inter-disciplinary buy-in, clear instruction for midwives and support from midwifery leaders were considered beneficial to implementing practice change in clinical areas. The TDF when used in combination with the COM-B was deemed useful to midwives wanting to lead practice change projects in clinical areas.

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Guide for recommendations on specific drug-related off-label treatment in palliative care: A Group Delphi process

10.21203/rs.2.17086/v1 ◽

2019 ◽

Author(s):

Constanze Remi ◽

Kathrin Weingärtner ◽

Vera Hagemann ◽

Claudia Bausewein ◽

Farina Hodiamont

Keyword(s):

Palliative Care ◽

Patient Safety ◽

Delphi Study ◽

Online Survey ◽

Delphi Process ◽

Treatment Quality ◽

Direct Patient Care ◽

Off Label Use ◽

Off Label ◽

Label Use

Abstract Background The use of drugs beyond their authorisation label, i.e. off-label-use, is common practice in palliative care with over 70% of off-label-use having little or no scientific support. Recommendations for off-label-use are essential to increase the safety of drug therapy and thus patient safety. The aim was to develop a guide for preparing and consenting drug-specific recommendations for off-label-use in palliative medicine.Methods Group Delphi Study with three rounds and a prior online survey. Participants represented professional groups working in palliative care involved in direct patient care and/or drug management (doctors, pharmacists, nurses) and various care settings (inpatient/community, university/non-university). Furthermore, representatives of relevant professional associations, experts with academic, non-clinical background and experts with international expertise were invited.Results For the preliminary online-survey 18/20 invited participants returned 18 questionnaires. Six domains, including identification of drugs, drug uses, assessment of evidence, formulation, consensus and updating of recommendations were generated and eventually 22 statements were included in the Group Delphi process. 15 experts participated in this consensus process. In combination with the survey results, consensus was achieved over a 28 statements after 3 Delphi rounds.Conclusions The resulted systematic approach for preparing and consenting drug-specific recommendations for off-label-use will allow to develop such recommendations with transparent and reproducible monographs. This will help to increase treatment quality and patient safety as well as security of decision-making in palliative care. The developed guide is part of a larger project aiming to provide therapy recommendations for areas that have little or no scientific evidence to date.

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Off-label drug use in home palliative care: A non-evidence-based established practice.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.31_suppl.225 ◽

2017 ◽

Vol 35 (31_suppl) ◽

pp. 225-225

Author(s):

Laura Velutti ◽

Carlotta Pavesi ◽

Diego Lopane ◽

Concetta Arcanà ◽

Annalisa Saetta ◽

...

Keyword(s):

Palliative Care ◽

Retrospective Analysis ◽

Evidence Based ◽

Care Pathways ◽

Administration Route ◽

Off Label Use ◽

Off Label ◽

Treatment Interruptions ◽

Infusion Duration ◽

Label Use

225 Background: Advanced cancer patients (pts) often present with multiple concomitant symptoms and off-label use of drugs (indications doses formulations administration route) is a common practice. Drugs mixture (DM) solutions by continuous administration are frequently used. However, evidence-based data in this setting is scarce. Methods: We performed a retrospective analysis of 576 consecutive care pathways provided by our Home Palliative Care (HC) Service from Jul 2010 to Jun 2017. Infusions were administered subcutaneously (sc) or by a venous (iv) access, by elastomeric pumps (EP) (5 days - 2 mL/h) with drugs diluted in 0.9% NaCl with no light protection. We analyzed: treated symptoms, drugs, doses/concentrations, solution transparency, administration route, infusion duration, clinical response, adverse events (AEs), compliance/treatment acceptability, device proper functioning, and treatment interruptions. Results: We analyzed 266 pts out of 576 care pathways treated with DM infusions, M/F 143/123, median age 70 yrs (21-92); treated symptoms: pain (50%), nausea/vomiting (20%), dyspnea/agitation (20%), dysphagia/mucositis (18%); infused drugs: morphine, midazolam, dexamethasone, ranitidine, metoclopramide, scopolamine, alizapride, haloperidol, furosemide, and ketorolac. Median number of drugs in the DM was 3 (1-6). Administration route was sc in 214 pts/80%, iv in 52 pts/20%. Median infusion duration was 5 days (0-64). Symptoms control was achieved within 72 h in 69% of pts. No AEs related to the infusion devices were observed. Compliance was good in 92% of pts, poor/inadequate in 8%. 5 EP malfunctions were observed: 1 human error, 1 device obstruction due to furosemide flocculation, 3 unexplained. Also, 3 pts required sc infusion interruption due to fluid accumulation near the injection site. Conclusions: This retrospective analysis on a large number of pts shows efficacy and tolerability of DM administration by EP in the HC setting. Treatment compliance was high, no AEs were observed, EP malfunction and therapy discontinuation were rare. However, there are still many open questions about the off-label use of drugs in this setting, and prospective trials are strongly suggested.

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Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies

International Psychogeriatrics ◽

10.1017/s1041610220001702 ◽

2020 ◽

pp. 1-29

Author(s):

Sally Bennett ◽

Kate Laver ◽

Margaret MacAndrew ◽

Elizabeth Beattie ◽

Lindy Clemson ◽

...

Keyword(s):

Systematic Review ◽

Quantitative Methods ◽

Psychological Symptoms ◽

Implementation Strategies ◽

Practice Change ◽

Evidence Based ◽

Pharmacological Interventions ◽

People With Dementia ◽

Implementation Studies ◽

Behavioral And Psychological Symptoms

ABSTRACT Objective This study aimed to identify the nature and effects of implementation strategies to increase the use of evidence-based, non-pharmacological interventions designed to reduce the frequency and/or severity of behavioral and psychological symptoms associated with dementia, for people living in the community. Design This was a systematic review of implementation studies. We searched six databases (in January 2019) and hand-searched reference lists of reports. Studies were included if they used quantitative methods evaluating the use of implementation strategies to increase the use of non-pharmacological interventions. These interventions had to have been tested in a randomized controlled trial (RCT) and found to reduce behavioral and psychological symptoms of dementia, for those living in the community. Studies needed to report the effect of the implementation on clinical practice, for example, a change in practice or the adoption of the intervention in community settings. Results Twelve studies were included: 11 one-group pre-post design studies and 1 cluster RCT. All studies reported practice change – the majority implementing a new intervention, with six different types of interventions implemented. All studies reported including using partnerships, new funding, educational strategies, and ongoing support and consultation. Seven implementation studies reported positive outcomes for clients on some aspect of behavior or depression for the person with dementia. Conclusions Implementation studies using multiple implementation strategies to increase the use of non-pharmacological interventions have demonstrated improvements in behavioral and psychological symptoms common in people with dementia, when provided by clinicians as part of their everyday work routines.

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Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery.

10.21203/rs.3.rs-40581/v2 ◽

2020 ◽

Author(s):

Annemarie De Leo ◽

Sara BAYES ◽

Dianne BLOXSOME ◽

Janice BUTT

Keyword(s):

Evidence Based Practice ◽

Theoretical Domains Framework ◽

Practice Change ◽

Evidence Based ◽

Valuable Insight ◽

Implementation Processes ◽

Change Factors ◽

Change Projects ◽

Formed Part ◽

Ebp Implementation

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Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery

Implementation Science Communications ◽

10.1186/s43058-020-00100-x ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

Annemarie De Leo ◽

Sara Bayes ◽

Dianne Bloxsome ◽

Janice Butt

Keyword(s):

Evidence Based Practice ◽

Theoretical Domains Framework ◽

Practice Change ◽

Evidence Based ◽

Valuable Insight ◽

Implementation Processes ◽

Change Factors ◽

Change Projects ◽

Formed Part ◽

Ebp Implementation

Abstract Background Despite the advancement of scientific research in the field of maternity care, midwives face challenges translating latest evidence into evidence-based practice (EBP) and express reticence towards leading practice change in clinical areas. This study aimed to explore midwifery leaders’ views on what factors help or hinder midwives’ efforts to translate latest evidence into everyday practice and consider them in relation to both the Capability, Opportunity, Motivation and Behaviour (COM-B) model and Theoretical Domains Framework (TDF). Methods This qualitative study formed part of a larger action research (AR) project that was designed to improve midwives’ EBP implementation capability. Data were obtained from eight Western Australian midwifery leaders who were employed in either managerial or executive positions within their organisation. Five midwives attended a focus group workshop and three opted for face-to-face interviews. Thematic analysis was used to code the transcribed data and group alike findings into sub-categories, which were collapsed to four major categories and one overarching core finding. These were mapped to a matrix combining the COM-B and TDF to establish the usability of these tools in midwifery contexts. Results Four major categories were developed from the data collected in this study. Three reported the hindrances midwives’ experienced when trying to initiate new EBPs: ‘For midwives, medical opposition and workplace culture are the biggest challenges’, ‘Fear can stop change: it’s personal for midwives’ and ‘Midwives are tired of fighting the battle for EBP; they need knowledge and the confidence to bring about practice change.’ The other major category highlighted factors midwives’ considered helpers of EBP: ‘Having stakeholder buy-in and strong midwifery leadership is a huge advantage.’ When mapped to the TDF and COM-B, these findings provided valuable insight into the helpers of and hindrances to evidence-based practice in midwifery. Conclusion Midwives are motivated to initiate evidence-based change yet have limited knowledge of implementation processes or the confidence to lead practice change. Factors such as inter-disciplinary buy-in, clear instruction for midwives and support from midwifery leaders were considered beneficial to implementing practice change in clinical areas. The TDF when used in combination with the COM-B was deemed useful to midwives wanting to lead practice change projects in clinical areas.

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Clinician-reported changes in octreotide prescribing for malignant bowel obstruction as a result of an adequately powered phase III study: A transnational, online survey

Palliative Medicine ◽

10.1177/0269216318778460 ◽

2018 ◽

Vol 32 (8) ◽

pp. 1363-1368 ◽

Cited By ~ 3

Author(s):

Rachel Campbell ◽

Nikki McCaffrey ◽

Linda Brown ◽

Meera R Agar ◽

Katherine Clark ◽

...

Keyword(s):

Palliative Care ◽

Relative Risk ◽

Confidence Interval ◽

Regression Model ◽

Bowel Obstruction ◽

Online Survey ◽

Practice Change ◽

Phase Iii ◽

Clinical Indication ◽

Malignant Bowel Obstruction

Background: Translating research evidence into clinical practice often has a long lag time. Aim: To determine the impact of a phase III randomised controlled trial on palliative care clinicians’ self-reported practice change. Design: Online survey about use of octreotide in managing inoperable malignant bowel obstruction due to cancer or its treatments distributed in November 2016, 2 years after the first publication of the study in a peer-reviewed journal. Demographic, self-reported practice and the reasons underpinning this were collected. Responses were aggregated to ‘practice modified’ or ‘practice not modified’. A multinomial regression model explored predictors of practice change. Setting: Members of the Australian New Zealand Society of Palliative Medicine. Results: Response rate was 20.8% (106/509): 55.6% were aged >50 years, 56.5% were female and 77% had previously prescribed octreotide for this clinical indication. Out of 106 respondents, 52 (49.1%) indicated modified practice (60.9% of those who had previously prescribed octreotide in this setting). In those who reported practice change, most frequently octreotide was now used when other therapies failed; for not changing practice, ‘more confirmatory evidence was needed’ was most often cited. In the regression model, older age (clinician age = 50–59 years; relative risk = 0.147; 95% confidence interval = 0.024–0.918; p = 0.04) and having practices with lower proportions of people treated with octreotide (0%–20%; relative risk = 0.039; 95% confidence interval = 0.002–0.768; p = 0.033) predicted greater self-reported practice change. Conclusion: Clinician-reported change in practice in the survey is seen in the majority of respondents. This suggests that there is a cohort of ‘early adopters’ within palliative care practice as new evidence becomes available.

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Development of targeted, theory-informed interventions to improve bronchiolitis management

BMC Health Services Research ◽

10.1186/s12913-021-06724-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Libby Haskell ◽

Emma J. Tavender ◽

Catherine L. Wilson ◽

Sharon O’Brien ◽

Franz E. Babl ◽

...

Keyword(s):

Influencing Factors ◽

Behaviour Change ◽

Mode Of Delivery ◽

Theoretical Domains Framework ◽

Practice Variation ◽

Practice Change ◽

Audit And Feedback ◽

Behaviour Change Techniques ◽

Evidence Based ◽

Theoretical Frameworks

Abstract Background Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. Methods A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. Results Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. Conclusion A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.

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Barriers and enablers to the implementation of multidisciplinary team meetings: a qualitative study using the theoretical domains framework

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011793 ◽

2020 ◽

pp. bmjqs-2020-011793

Author(s):

Ashika D Maharaj ◽

Sue M Evans ◽

John R Zalcberg ◽

Liane J Ioannou ◽

Marnie Graco ◽

...

Keyword(s):

Pancreatic Cancer ◽

Palliative Care ◽

Multidisciplinary Team ◽

Social Influences ◽

Theoretical Domains Framework ◽

Environmental Context ◽

Evidence Based ◽

Common Belief ◽

Barriers And Enablers ◽

Belief Statements

BackgroundEvidence-based clinical practice guidelines recommend discussion by a multidisciplinary team (MDT) to review and plan the management of patients for a variety of cancers. However, not all patients diagnosed with cancer are presented at an MDT.Objectives(1) To identify the factors (barriers and enablers) influencing presentation of all patients to, and the perceived value of, MDT meetings in the management of patients with pancreatic cancer and; (2) to identify potential interventions that could overcome modifiable barriers and enhance enablers using the theoretical domains framework (TDF).MethodsSemistructured interviews were conducted with radiologists, surgeons, medical and radiation oncologists, gastroenterologists, palliative care specialists and nurse specialists based in New South Wales and Victoria, Australia. Interviews were conducted either in person or via videoconferencing. All interviews were recorded, transcribed verbatim, deidentified and data were thematically coded according to the 12 domains explored within the TDF. Common belief statements were generated to compare the variation between participant responses.ResultsIn total, 29 specialists were interviewed over a 4-month period. Twenty-two themes and 40 belief statements relevant to all the TDF domains were generated. Key enablers influencing MDT practices included a strong organisational focus (social/professional role and identity), beliefs about the benefits of an MDT discussion (beliefs about consequences), the use of technology, for example, videoconferencing (environmental context and resources), the motivation to provide good quality care (motivation and goals) and collegiality (social influences). Barriers included: absence of palliative care representation (skills), the number of MDT meetings (environmental context and resources), the cumulative cost of staff time (beliefs about consequences), the lack of capacity to discuss all patients within the allotted time (beliefs about capabilities) and reduced confidence to participate in discussions (social influences).ConclusionsThe internal and external organisational structures surrounding MDT meetings ideally need to be strengthened with the development of agreed evidence-based protocols and referral pathways, a focus on resource allocation and capabilities, and a culture that fosters widespread collaboration for all stages of pancreatic cancer.

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