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

Wit, Kerstin de; Curran, Janet; Thoma, Brent; Dowling, Shawn; Lang, Eddy; Kuljic, Nebojsa; Perry, Jeffrey J.; Morrison, Laurie J.

doi:10.1017/cem.2017.432

Cited by 30 publications

(38 citation statements)

References 36 publications

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“…Continuous monitoring, audit, and feedback for sustained change Monitoring, audit, and feedback (A&F) of healthcare improvement initiatives are important interventions to facilitate buy-in, maintain compliance and ensure the continuation of improved outcomes (39). Our ndings pertaining to how A&F supports ongoing staff engagement, by hearing, and seeing data in a group atmosphere are well aligned with the literature (39)(40)(41).…”

Section: Learning Collaboratives As a Mechanism For Sustained Changementioning

confidence: 74%

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

Flynn

Mrklas

Campbell

et al. 2020

Preprint

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Background: In 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these efforts. Methods: We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN initiatives. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research. Results: We conducted thirty realist interviews in two cases and found four important mechanisms facilitating sustainability: the use of a collaborative approach audit & feedback, the informal leadership role, and patient stories. Informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the initiative. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of initiative sustainability. Patient stories demonstrated the initiatives’ impact on patient outcomes, motivating staff to want to continue doing the initiative, and increasing the likelihood of its sustainability. Conclusions: There are important contextual factors and mechanisms within sustainment processes that may apply to systems change implementers. Our research revealed the causal relationship between implementation and sustainability and how outcomes from implementation shape sustainability contexts. Future work is needed to evaluate the effectiveness of informal leadership, learning collaboratives, audit-feedback, and patient stories as sustainability interventions, to generate better guidance on planning sustainable improvements with long term impact.

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Section: Learning Collaboratives As a Mechanism For Sustained Changementioning

confidence: 74%

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

Flynn

Mrklas

Campbell

et al. 2020

Preprint

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“…The implementation strategy is based on the knowledge translation recommendations from CAEP. 11 The components of the intervention are detailed in Table 1. This implementation strategy was discussed at each site by engaging with local champions, hospitals managers, nurses, diagnostic imaging staff, support staff, and physicians to identify and implement strategies to overcome local barriers.…”

Section: Methodsmentioning

confidence: 99%

Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Germini

Afzal

et al. 2020

Preprint

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Background: Many evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol.Methods: We conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018 to February 28, 2020. Components of the intervention were: clinical leadership endorsement; a new pathway for PE testing; physician education; personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites; capturing data on ≥ 80% of all CTPAs ordered in the EDs; timely access to electronic data; rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time; time required for manual data extraction and feedback preparation ≤ 2 day per week in total.Results: The intervention was successfully implemented in two out of three sites. 5,094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 hours).Conclusions: We proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED.Registration: The study was not registered.

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“…The implementation plan included multi-modal implementation strategies, including educational sessions, a support video, clinical champions, audit and feedback, environmental changes and advertisements, which are common, accessible strategies that can be adapted and used at other sites. Other emergency based implementation studies include multiple strategies; with the most common strategies reported in a systematic review of emergency behaviour change being reminders, educational meetings, educational materials and clinical practice guidelines [42]. The ChIP implementation included a combination of all of these strategies.…”

Section: Implementation Strategy Scalabilitymentioning

confidence: 99%

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

Kourouche

Curtis

Munroe

et al. 2020

Preprint

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

Abstract: We 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.

Cited by 30 publications

References 36 publications

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

Feasibility of a quality improvement project with an interrupted time series design to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

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

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