Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol

Abstract Background Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a ‘clinical care bundle’ for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the “E-MOTIVE” bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice. Methods We will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops. Discussion This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective. Trial registration: ClinicalTrials.gov: NCT04341662

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Implementing the use of objective medication adherence data in routine clinical practice via the digital CFHealthHub platform: situation analysis and strategy development using the theoretical domains framework

10.21203/rs.3.rs-847358/v1 ◽

2021 ◽

Author(s):

Carla Girling ◽

Anna Packham ◽

Louisa Robinson ◽

Madelynne A Arden ◽

Daniel Hind ◽

...

Keyword(s):

Cystic Fibrosis ◽

Medication Adherence ◽

Behaviour Change ◽

Implementation Strategy ◽

Clinical Care ◽

Theoretical Domains Framework ◽

Behaviour Change Techniques ◽

Implementation Phase ◽

Adherence Data ◽

Healthcare Innovation

Abstract Background Preventative inhaled treatments preserve lung function and reduce exacerbations in Cystic Fibrosis (CF). Self-reported adherence to these treatments is over-estimated. An online platform (CFHealthHub) has been developed with patients and clinicians to display real-time objective adherence data from dose-counting nebulisers, so that clinical teams can offer informed treatment support. Methods In this paper, we identify pre-implementation barriers to healthcare practitioners performing two key behaviours: accessing objective adherence data through the website CFHealthHub and discussing medication adherence with patients. We aimed to understand barriers during the pre-implementation phase, so that appropriate strategy could be developed for the scale up of implementing objective adherence data in 19 CF centres. Thirteen semi-structured interviews were conducted with healthcare practitioners working in three UK CF centres. Qualitative data were coded using the Theoretical Domains Framework (TDF), which describes 14 validated domains to implementation behaviour change. Results Analysis indicated that an implementation strategy should address all 14 domains of the TDF to successfully support implementation. Participants did not report routines or habits for using objective adherence data in clinical care. Examples of salient barriers included skills, beliefs in consequences, and social influence and professional roles. The results also affirmed a requirement to address organisational barriers. Relevant behaviour change techniques were selected to develop implementation strategy modules using the behaviour change wheel approach to intervention development. ConclusionsThis paper demonstrates the value of applying the TDF at pre-implementation, to understand context and to support the development of a situationally relevant implementation strategy. Contribution to the literature· Research indicates that the implementation of healthcare innovations may be more likely to succeed when context and theory are taken into consideration. · In this study, healthcare professionals identified barriers to two behaviours that were key to the implementation of a national Cystic Fibrosis (CF) healthcare innovation. By coding barriers to the Theoretical Domains Framework (TDF), a contextually relevant implementation strategy was developed, with a focus on clinician behaviour change. · The study highlights the challenges CF teams face when implementing new remote monitoring of medication adherence, and provides an important opportunity to apply the TDF in the pre-implementation phase of a healthcare innovation.

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Juvenile Probation Officer Decision-Making in a Reforming State: Assessing the Application of Evidence-Based Principles

Criminal Justice and Behavior ◽

10.1177/0093854820925112 ◽

2020 ◽

Vol 47 (9) ◽

pp. 1136-1155 ◽

Cited By ~ 1

Author(s):

Joel Miller ◽

Krissinda Palmer

Keyword(s):

Decision Making ◽

Implementation Strategy ◽

Probation Officer ◽

Routine Practice ◽

Evidence Based ◽

Juvenile Probation ◽

Risk Levels ◽

Rnr Model ◽

Risk Need Responsivity ◽

Experimental Survey

Whereas research has shown improvements in decision-making shortly after the introduction of risk/need assessment (RNA) tools, studies of routine practice nonetheless show shortcomings in RNA utilization. The current study uses an experimental survey-based vignette method to assess juvenile probation officer decision-making several years into a sustained evidence-based effort to implement an RNA in Pennsylvania. Consistent with the risk-need-responsivity (RNR) model, results show officer decisions correspond with clients’ risk and need. Moreover, adherence to the RNR model was found for clients across risk levels and offense categories. However, officers often relied on services for low-risk clients, and made decisions about interventions based on offense characteristics. Results suggest a discretionary form of decision-making, taking cues from within and beyond the RNR model, including from punitive and traditional welfare-oriented approaches. Findings highlight the challenges of producing RNR-consistent decision-making, even when using a sustained scientific RNA implementation strategy.

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Implementation Evaluation of a Multidisciplinary Blunt Chest Injury Care Bundle (ChIP): Fidelity of Delivery

10.21203/rs.3.rs-52188/v1 ◽

2020 ◽

Author(s):

Sarah Kourouche ◽

Kate Curtis ◽

Belinda Munroe ◽

Jack Lyons ◽

Ian Carey ◽

...

Keyword(s):

Behaviour Change ◽

Implementation Strategy ◽

Implementation Fidelity ◽

Chest Injury ◽

Care Bundle ◽

Behaviour Change Techniques ◽

Evidence Based ◽

Regional Analgesia ◽

Implementation Evaluation ◽

Chest Wall Injury

Abstract Background: Ineffective or delayed treatment of patients with blunt chest wall injury results in high rates of morbidity and mortality. A blunt chest injury care bundle protocol (ChIP) was developed and implemented to improve evidence-based care for these patients at two regional hospitals in Australia. ChIP is an early notification system to notify specialist clinician ‘responders’ to prescribe and commence treatment for patients with blunt chest injury in the emergency department (ED). A multi-pronged implementation strategy developed using the Behaviour Change Wheel (BCW), including seven intervention functions and 15 behaviour change techniques, guided implementation. Fidelity to the implementation strategy was high, with 97.5% fully or partially implemented. Implementation fidelity is the extent to which an intervention has been implemented as intended; it affects the internal and external validity of implementation. This study evaluates the fidelity of intervention delivery (fidelity, dose and reach) at two hospitals. Methods: Pre-post implementation evaluation study. The characteristics of patients, rate of ChIP activations and components of ChIP received by eligible patients were compared pre (1 July 2015 to 21 November 2017) and post (22 November 2017 to 30 June 2019) intervention. Sample medians were compared using the non-parametric median test, with the 95% confidence of the difference estimated using the Hodges-Lehmann estimate. Differences in proportions for categorical data were compared with two-sample z-test. Logistic regression was used to adjust for group differences. Results: Overall, 97.1% of eligible patients received ChIP over the 19-month post-implementation period. Compared to the pre-implementation group the post-implementation group, were more likely to receive evidence-based treatments including high flow nasal cannula (OR=6.8 (4.8,9.6)), incentive spirometry in ED (OR=7.5 (3.2,17.6)), regular analgesia (OR=2.4 (1.5,3.8)), regional analgesia (OR=2.8 (1.5, 5.3)), Patient controlled analgesia (OR=1.8 (1.3,2.4)), and multiple specialist team reviews e.g. ICU liaison (OR=10.7 (6.9,16.7)). Conclusions: High fidelity of delivery was achieved and sustained for ChIP for the implementation of a complex intervention in the emergency context with a robust implementation plan based on theoretical frameworks. Findings from this evaluation can inform future implementation of ChIP and other multidisciplinary interventions in an emergency or acute care context. Trial registration: ANZCTR: ACTRN12618001548224, approved 17/09/2018

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Barriers and facilitators to promoting evidence uptake in Chinese medicine: a qualitative study in Hong Kong

BMC Complementary Medicine and Therapies ◽

10.1186/s12906-021-03372-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Charlene Hoi Lam Wong ◽

Jeffrey Van Ho Tse ◽

Per Nilsen ◽

Leonard Ho ◽

Irene Xin Yin Wu ◽

...

Keyword(s):

Hong Kong ◽

Chinese Medicine ◽

Randomized Trials ◽

Clinical Evidence ◽

Barriers And Facilitators ◽

World Health ◽

Routine Practice ◽

Evidence Based ◽

The World ◽

Evidence Based Healthcare

Abstract Background In response to the World Health Organization’s recommendation, policy makers have been adopting evidence-based healthcare approach to promote the development of traditional, complementary and integrative medicine (TCIM) into Hong Kong’s health system. Disseminating synopses of clinical evidence from systematic reviews or randomized trials is regarded as a potentially effective strategy to promote evidence uptake. The study aimed to identify barriers and facilitators to implementing this strategy among Hong Kong Chinese medicine practitioners (CMPs). Methods Twenty-five CMPs aged under 45 years and trained in Hong Kong after reunification with China in 1997 were interviewed individually. Four clinical evidence synopses of randomized trials and systematic reviews on Chinese medicine interventions were presented, and CMPs were asked to comment on their applicability in routine practice. The Consolidated Framework for Implementation Research (CFIR) was applied to guide interview and analysis. Results The barriers included: i) CMPs’ perceived difficulties in applying complex evidence in decision-making and ii) inadequate training and limited consultation time. The facilitators were i) availability of publicly accessible and user-friendly synopses, ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders, iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients’ demand for evidence-based clinical advice. Besides, i) CMPs’ knowledge and beliefs in evidence-based healthcare approach, ii) presentations of evidence-based information in the synopses, and iii) clinical decision making as influenced by quality of evidence reported acted as both barriers and facilitators. Conclusions This CFIR-based qualitative study investigated how the World Health Organization recommendation of promoting evidence use in routine practice was perceived by CMPs trained in Hong Kong after reunification with China in 1997. Key barriers and facilitators to applying evidence were identified. Such results will inform tailoring of implementation strategies for promoting evidence uptake, in the context of a well-developed health system dominated by conventional medicine.

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Home programmes based on evidence of best practice for children with unilateral cerebral palsy: Occupational therapists’ perceptions

British Journal of Occupational Therapy ◽

10.1177/0308022619898073 ◽

2020 ◽

Vol 83 (7) ◽

pp. 447-457

Author(s):

Yvonne M Milton ◽

Sarah A Roe ◽

Katie V Newby

Keyword(s):

Cerebral Palsy ◽

Occupational Therapy ◽

Best Practice ◽

Theoretical Domains Framework ◽

Occupational Therapists ◽

Routine Practice ◽

Evidence Based ◽

Unique Contribution ◽

Framework Analysis ◽

Unilateral Cerebral Palsy

Introduction Evidence-based occupational therapy home programmes for children with unilateral cerebral palsy have demonstrated efficacy; however, uptake into routine practice is varied. The aim of this study was to gain a deeper understanding of the therapist-perceived supports and barriers to using occupational therapy home programmes for children with unilateral cerebral palsy, based on evidence of best practice in the United Kingdom. Method Fourteen occupational therapists completed semi-structured telephone interviews. Using a qualitative framework analysis approach, support and barrier factors were indexed against the Theoretical Domains Framework, before being categorised more broadly using the Capability, Opportunity, Motivation and Behaviour Model. Findings Common supports included: (a) strong leadership within the team to facilitate the translation of occupational therapy home programmes and evidence-based interventions into service-specific protocols; (b) knowledge exchange within professional networks and (c) mentorship. Common barriers included: (a) lack of resources; (b) restricted opportunities to review occupational therapy home programmes and (c) difficulties keeping up-to-date with the evidence in this area. Conclusion To be effective, occupational therapy home programmes need to be based on evidence of best practice; analysis indicated an urgent need to capture outcomes, record parental practice, further integrate ‘occupation’ within goal-setting, and develop use of conceptual models of practice to both enhance family-centred care and articulate the profession’s unique contribution.

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Using the theoretical domains framework to inform strategies to support dietitians undertaking body composition assessments in routine clinical care

BMC Health Services Research ◽

10.1186/s12913-021-06375-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chloe J. D. Jobber ◽

Shelley A. Wilkinson ◽

Elyssa K. Hughes ◽

Fiona Nave ◽

Barbara S. van der Meij

Keyword(s):

Body Composition ◽

Clinical Care ◽

Theoretical Domains Framework ◽

Implementation Strategies ◽

Implementation Process ◽

Tertiary Hospital ◽

Environmental Context ◽

Routine Practice ◽

Body Composition Assessment ◽

Knowledge To Action

Abstract Background Malnutrition, sarcopenia and cachexia are clinical wasting syndromes characterised by muscle loss. Systematic monitoring by body composition assessment (BCA) is recommended for the diagnosis, treatment and monitoring of the syndrome(s). This study investigated practices, competency, and attitudes of Australian dietitians regarding BCA, to inform a local implementation process. Methods Applying the Action cycle in the Knowledge to Action framework, surveys were distributed to the 26 dietitians of an 800-bed tertiary hospital. The survey assessed barriers and enablers to performing routine BCA in clinical care. Results were categorised using the Theoretical Domains Framework (TDF) and suitable interventions mapped using the Behaviour Change Wheel. Results Twenty-two dietitians (84.6%) completed the survey. Barriers to BCA were identified in all TDF domains, particularly in Knowledge, Skills, Social/professional role and identity, Beliefs about capabilities, and Environmental context and resources. Enablers existed in domains of: Skills; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Intentions; Optimism; Reinforcement. Conclusions This study showed that hospital dietitians experience individual, team, and organisational barriers to adopt BCAs in clinical practice. We were able to formulate targeted implementation strategies to overcome these barriers to assist BCA adoption into routine practice.

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A qualitative assessment of factors influencing implementation and sustainability of evidence-based tobacco use treatment in Vietnam health centers

Implementation Science ◽

10.1186/s13012-020-01035-6 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Nancy VanDevanter ◽

Milkie Vu ◽

Ann Nguyen ◽

Trang Nguyen ◽

Hoang Van Minh ◽

...

Keyword(s):

Public Health ◽

Health Systems ◽

Implementation Strategy ◽

Local Level ◽

World Health ◽

Qualitative Assessment ◽

Evidence Based ◽

Care Providers ◽

Public Health Systems ◽

Factors Influencing

Abstract Background Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability. Methods We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis. Results Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains. Conclusion Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam’s. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization’s goals promoting access to effective treatment for all tobacco users. Trial registration NCT02564653, registered September 2015

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P115: Improving the diagnosis of pulmonary embolism in the emergency department

CJEM ◽

10.1017/cem.2020.321 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S106-S106

Author(s):

K. de Wit ◽

S. Zarabi ◽

T. Chan ◽

F. Germini ◽

S. Mondoux ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Qualitative Interviews ◽

Theoretical Domains Framework ◽

Ct Scanning ◽

Evidence Based ◽

Novel Approach ◽

Wells Score ◽

And Function ◽

D Dimer

Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.

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Exploring Barriers and Enablers to Dietitians Completing Body Composition Assessments as Part of Routine Clinical Care

10.21203/rs.3.rs-113964/v1 ◽

2020 ◽

Author(s):

Chloe Jobber ◽

Shelley Wilkinson ◽

Elyssa Hughes ◽

Fiona Nave ◽

Barbara van der Meij

Keyword(s):

Body Composition ◽

Clinical Care ◽

Theoretical Domains Framework ◽

Implementation Strategies ◽

Implementation Process ◽

Routine Practice ◽

Muscle Loss ◽

Body Composition Assessment ◽

Knowledge To Action ◽

Barriers And Enablers

Abstract Background: Malnutrition, sarcopenia and cachexia are clinical wasting syndromes characterised by muscle loss. Systematic monitoring by body composition assessment (BCA) is recommended for the diagnosis, treatment and monitoring of the syndrome(s). However, limited literature exists regarding integration of BCA into routine practice. This study investigated practices, competency, and attitudes of Australian dietitians regarding BCA, to inform a local implementation process.Methods:Applying the Action cycle in the Knowledge to Action framework, surveys were distributed to the 26 dietitians in our department. The survey assessed barriers and enablers to performing routine BCA in clinical care. Results were categorised using the Theoretical Domains Framework (TDF) and suitable interventions mapped using the Behaviour Change Wheel. Results:Twenty-two dietitians (84.6%) completed the survey. Barriers to BCA were identified in all TDF domains. Enablers existed in domains of: Skills; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Intentions; Optimism; Reinforcement. Conclusions:This study showed that hospital dietitians experience numerous individual, team, and organisational barriers to adopt BCAs in clinical practice. Information on barriers and enablers and implementation strategies have been suggested to overcome these barriers to assist BCA adoption into routine practice.

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