A qualitative study of barriers to the implementation of a rheumatoid arthritis guideline among generalist and specialist physical therapists.

PubMed

van Bodegom-Vos, Leti; Verhoef, John; Dickmann, Margot; Kleijn, Marjon; van Vliet, Ingrid; Hurkmans, Emalie; van der Wees, Philip; Vliet Vlieland, Thea

2012-10-01

Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied. Objectives The objective of this study was to identify the similarities and differences in barriers to the implementation of a Dutch rheumatoid arthritis (RA) guideline by generalist and specialist physical therapists. Design This observational study consisted of 4 focus group interviews in which 24 physical therapists (13 generalist and 11 specialist physical therapists) participated. Physical therapists were asked to discuss barriers to the implementation of the RA guideline. Data were analyzed qualitatively using a directed approach to content analysis. Both the interviews and the interview analysis were informed by a previously developed conceptual framework. Besides a number of similarities (eg, lack of time), the present study showed important, although subtle, differences in barriers to the implementation of the RA guideline between generalist physical therapists and specialist physical therapists. Generalist physical therapists more frequently reported difficulties in interpreting the guideline (cognitive barriers) and had less favorable opinions about the guideline (affective barriers) than specialist physical therapists. Specialist physical therapists were hampered by external barriers that are outside the scope of generalist physical therapists, such as a lack of agreement about the roles and responsibilities of medical professionals involved in the care of the same patient. The identified differences in barriers to the implementation of the RA guideline indicated that the effectiveness of implementation strategies could be improved by tailoring them to the level of specialization of physical therapists. However, it is expected that tailoring implementation strategies to barriers that hamper both generalist and specialist physical therapists will have a larger effect on the implementation of the RA guideline.

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines.

PubMed

Flodgren, Gerd; Hall, Amanda M; Goulding, Lucy; Eccles, Martin P; Grimshaw, Jeremy M; Leng, Gillian C; Shepperd, Sasha

2016-08-22

The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs. To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective. We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites. We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area. Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines. We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service. Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.

Cochrane Qualitative and Implementation Methods Group guidance series-paper 6: reporting guidelines for qualitative, implementation, and process evaluation evidence syntheses.

PubMed

Flemming, Kate; Booth, Andrew; Hannes, Karin; Cargo, Margaret; Noyes, Jane

2018-05-01

To outline contemporary and novel developments for the presentation and reporting of syntheses of qualitative, implementation, and process evaluation evidence and provide recommendations for the use of reporting guidelines. An overview of reporting guidelines for qualitative, implementation, and process evaluation evidence syntheses drawing on current international literature and the collective expert knowledge of the Cochrane Qualitative and Implementation Methods Group. Several reporting guidelines exist that can be used or adapted to report syntheses of qualitative, implementation, and process evaluation evidence. Methods to develop individual guidance varied. The use of a relevant reporting guideline can enhance the transparency, consistency, and quality of reporting. Guidelines that exist are generic, method specific, and for particular aspects of the reviewing process, searching. Caution is expressed over the potential for reporting guidelines to produce a mechanistic approach moving the focus away from the content and toward the procedural aspects of the review. The use of a reporting guideline is recommended and a five-step decision flowchart to guide the choice of reporting guideline is provided. Gaps remain in method-specific reporting guidelines such as mixed-study, implementation, and process evaluation evidence syntheses. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation.

PubMed

Hawkes, Claire; Foxcroft, David R; Yerrell, Paul

2010-09-01

This paper is a report of an investigation of the development, implementation and outcomes of a clinical guideline for nurse-led early extubation of adult coronary artery bypass graft patients. Healthcare knowledge translation and utilization is an emerging but under-developed research area. The complex context for guideline development and use is methodologically challenging for robust and rigorous evaluation. This study contributes one such evaluation. This was a mixed methods evaluation, with a dominant quantitative study with a secondary qualitative study in a single UK cardiac surgery centre. An interrupted time series study (N = 567 elective coronary artery bypass graft patients) with concurrent within person controls was used to measure the impact of the guideline on the primary outcome: time to extubation. Semi-structured interviews with 11 clinical staff, informed by applied practitioner ethnography, explored the process of guideline development and implementation. The data were collected between January 2001 and January 2003. There was no change in the interrupted time series study primary outcome as a consequence of the guideline implementation. The qualitative study identified three themes: context, process and tensions highlighting that the guideline did not require clinicians to change their practice, although it may have helped maintain practice through its educative role. Further investigation and development of appropriate methods to capture the dynamism in healthcare contexts and its impact on guideline implementation seems warranted. Multi-site mixed methods investigations and programmes of research exploring knowledge translation and utilization initiatives, such as guideline implementation, are needed.

Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design.

PubMed

Cretin, S; Farley, D O; Dolter, K J; Nicholas, W

2001-08-01

Implementing clinical practice guidelines to change patient outcomes presents a challenge. Studies of single interventions focused on changing provider behavior demonstrate modest effects, suggesting that effective guideline implementation requires a multifaceted approach. Traditional biomedical research designs are not well suited to evaluating systems interventions. RAND and the Army Medical Department collaborated to develop and evaluate a system for implementing guidelines and documenting their effects on patient care. The evaluation design blended quality improvement, case study, and epidemiologic methods. A formative evaluation of implementation process and an outcome evaluation of patient impact were combined. Guidelines were implemented in 3 successive demonstrations targeting low back pain, asthma, and diabetes. This paper reports on the first wave of 4 facilities implementing a low back pain guideline. Organizational climate and culture, motivation, leadership commitment, and resources were assessed. Selected indicators of processes and outcomes of care were compared before, during, and after guideline implementation at the demonstration facilities and at comparison facilities. Logistic regression analysis was used to test for guideline effects on patient care. Process evaluation documented varied approaches to quality improvement across sites. Outcome evaluation revealed a significant downward trend in the percentage of acute low back pain patients referred to physical therapy or chiropractic care (10.7% to 7.2%) at demonstration sites and no such trend at control sites. Preliminary results suggest the power of this design to stimulate improvements in guideline implementation while retaining the power to evaluate rigorously effects on patient care.

The Instrument for Measuring the Implementation Situation of Traditional Chinese Medicine Guideline: Evaluation and Application

PubMed Central

Wang, Yangyang; Chen, Yaolong; Wang, Xiaoyun; Deng, Jingwen

2017-01-01

Clinical practice guidelines play an important role in reducing the variations in clinical practices and improving the quality of care. To assess the real effect, measuring its implementation situation is needed. The implementation situation can be reflected by testing the consistency between the actual clinical practice and the guideline. We constructed an instrument to measure the implementation situation of Traditional Chinese Medicine (TCM) guideline through consistency testing. The main objectives of our study were to validate the instrument and evaluate the implementation situation of menopause syndrome guideline of TCM, using the data from the consistency test of comparing the medical records with the guideline. A total of 621 cases were included for data analysis. Cronbach's Alpha coefficient is 0.73. The model fit of 7 items in four dimensions was good (SRMR = 0.04; GFI = 0.97; NFI = 0.97; TLI = 0.96; CFI = 0.98; AGFI = 0.90). This instrument is of good reliability and validity. It can help the guideline developers to measure the implementation situation, find the reasons affecting the implementation, and revise the guideline. The method of using consistency test to measure the implementation situation may provide a sample for evaluating the guideline implementation in other fields. PMID:29234379

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences.

PubMed

Chimeddamba, Oyun; Peeters, Anna; Ayton, Darshini; Tumenjargal, Enkhjargal; Sodov, Sonin; Joyce, Catherine

2015-08-11

Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting. A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework. The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants' commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy. This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Cancer related fatigue: implementing guidelines for optimal management.

PubMed

Pearson, Elizabeth J M; Morris, Meg E; McKinstry, Carol E

2017-07-18

Cancer-related fatigue (CRF) is a key concern for people living with cancer and can impair physical functioning and activities of daily living. Evidence-based guidelines for CRF are available, yet inconsistently implemented globally. This study aimed to identify barriers and enablers to applying a cancer fatigue guideline and to derive implementation strategies. A mixed-method study explored the feasibility of implementing the CRF guideline developed by the Canadian Association for Psychosocial Oncology (CAPO). Health professionals, managers and consumers from different practice settings participated in a modified Delphi study with two survey rounds. A reference group informed the design of the study including the surveys. The first round focused on guideline characteristics, compatibility with current practice and experience, and behaviour change. The second survey built upon and triangulated the first round. Forty-five health practitioners and managers, and 68 cancer survivors completed the surveys. More than 75% of participants endorsed the CAPO cancer related fatigue guidelines. Some respondents perceived a lack of resources for accessible and expert fatigue management services. Further barriers to guideline implementation included complexity, limited practical details for some elements, and lack of clinical tools such as assessment tools or patient education materials. Recommendations to enhance guideline applicability centred around four main themes: (1) balancing the level of detail in the CAPO guideline with ease of use, (2) defining roles of different professional disciplines in CRF management, (3) how best to integrate CRF management into policy and practice, (4) how best to ensure a consumer-focused approach to CRF management. Translating current knowledge on optimal management of CRF into clinical practice can be enhanced by the adoption of valid guidelines. This study indicates that it is feasible to adopt the CAPO guidelines. Clinical application may be further enhanced with guideline adaptation, professional education and integration with existing practices.

Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions

PubMed Central

Overington, Jeff D.; Huang, Yao C.; Abramson, Michael J.; Brown, Juliet L.; Goddard, John R.; Bowman, Rayleen V.; Fong, Kwun M.

2014-01-01

Chronic obstructive pulmonary disease (COPD) is a complex chronic lung disease characterised by progressive fixed airflow limitation and acute exacerbations that frequently require hospitalisation. Evidence-based clinical guidelines for the diagnosis and management of COPD are now widely available. However, the uptake of these COPD guidelines in clinical practice is highly variable, as is the case for many other chronic disease guidelines. Studies have identified many barriers to implementation of COPD and other guidelines, including factors such as lack of familiarity with guidelines amongst clinicians and inadequate implementation programs. Several methods for enhancing adherence to clinical practice guidelines have been evaluated, including distribution methods, professional education sessions, electronic health records (EHR), point of care reminders and computer decision support systems (CDSS). Results of these studies are mixed to date, and the most effective ways to implement clinical practice guidelines remain unclear. Given the significant resources dedicated to evidence-based medicine, effective dissemination and implementation of best practice at the patient level is an important final step in the process of guideline development. Future efforts should focus on identifying optimal methods for translating the evidence into everyday clinical practice to ensure that patients receive the best care. PMID:25478199

Guideline attribute and implementation preferences among physicians in multiple health systems.

PubMed

Stone, Tamara T; Schweikhart, Sharon B; Mantese, Annamarie; Sonnad, Seema S

2005-01-01

Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice. This study aimed to understand physician preferences for guideline format, placement, content, evidence, and learning strategies in different clinical environments. Semistructured telephone interviews were conducted with 500 randomly selected physicians from 4 major US health systems who were involved in the treatment of patients with acute myocardial infarction or pediatric asthma. Paired sample t tests and Tukey's method of comparisons determined the relative ranking of physicians' guideline implementation preferences. Physicians preferred guidelines located on the front of the patient chart, in palm pilots, or in progress notes and presented as flow charts/flow diagrams, algorithms, or preprinted orders that contain strategies to minimize readmits/encourage self-management and immediate treatment flows. Discussions with colleagues and continuing medical education are the most effective strategies for encouraging guideline use, and randomized controlled trials remain the most persuasive medical evidence. Health care organizations must align guideline implementation efforts with physician preferences to encourage utilization. The results of this study reveal systematic physician preferences for guideline implementation that can be applied to clinical settings to encourage guideline use by physicians.

The guideline implementability research and application network (GIRAnet): an international collaborative to support knowledge exchange: study protocol.

PubMed

Gagliardi, Anna R; Brouwers, Melissa C; Bhattacharyya, Onil K

2012-04-02

Modifying the format and content of guidelines may facilitate their use and lead to improved quality of care. We reviewed the medical literature to identify features desired by different users and associated with guideline use to develop a framework of implementability and found that most guidelines do not contain these elements. Further research is needed to develop and evaluate implementability tools. We are launching the Guideline Implementability Research and Application Network (GIRAnet) to enable the development and testing of implementability tools in three domains: Resource Implications, Implementation, and Evaluation. Partners include the Guidelines International Network (G-I-N) and its member guideline developers, implementers, and researchers. In phase one, international guidelines will be examined to identify and describe exemplar tools. Indication-specific and generic tools will populate a searchable repository. In phase two, qualitative analysis of cognitive interviews will be used to understand how developers can best integrate implementability tools in guidelines and how health professionals use them for interpreting and applying guidelines. In phase three, a small-scale pilot test will assess the impact of implementability tools based on quantitative analysis of chart-based behavioural outcomes and qualitative analysis of interviews with participants. The findings will be used to plan a more comprehensive future evaluation of implementability tools. Infrastructure funding to establish GIRAnet will be leveraged with the in-kind contributions of collaborating national and international guideline developers to advance our knowledge of implementation practice and science. Needs assessment and evaluation of GIRAnet will provide a greater understanding of how to develop and sustain such knowledge-exchange networks. Ultimately, by facilitating use of guidelines, this research may lead to improved delivery and outcomes of patient care.

Enhancing implementation of tobacco use prevention and cessation counselling guideline among dental providers: a cluster randomised controlled trial

PubMed Central

2011-01-01

Background Tobacco use adversely affects oral health. Tobacco use prevention and cessation (TUPAC) counselling guidelines recommend that healthcare providers ask about each patient's tobacco use, assess the patient's readiness and willingness to stop, document tobacco use habits, advise the patient to stop, assist and help in quitting, and arrange monitoring of progress at follow-up appointments. Adherence to such guidelines, especially among dental providers, is poor. To improve guideline implementation, it is essential to understand factors influencing it and find effective ways to influence those factors. The aim of the present study protocol is to introduce a theory-based approach to diagnose implementation difficulties of TUPAC counselling guidelines among dental providers. Methods Theories of behaviour change have been used to identify key theoretical domains relevant to the behaviours of healthcare providers involved in implementing clinical guidelines. These theoretical domains will inform the development of a questionnaire aimed at assessing the implementation of the TUPAC counselling guidelines among Finnish municipal dental providers. Specific items will be drawn from the guidelines and the literature on TUPAC studies. After identifying potential implementation difficulties, we will design two interventions using theories of behaviour change to link them with relevant behaviour change techniques aiming to improve guideline adherence. For assessing the implementation of TUPAC guidelines, the electronic dental record audit and self-reported questionnaires will be used. Discussion To improve guideline adherence, the theoretical-domains approach could provide a comprehensive basis for assessing implementation difficulties, as well as designing and evaluating interventions. After having identified implementation difficulties, we will design and test two interventions to enhance TUPAC guideline adherence. Using the cluster randomised controlled design, we aim to provide further evidence on intervention effects, as well as on the validity and feasibility of the theoretical-domain approach. The empirical data collected within this trial will be useful in testing whether this theoretical-domain approach can improve our understanding of the implementation of TUPAC guidelines among dental providers. Trial registration Current Controlled Trials ISRCTN15427433 PMID:21320312

What hospitals need to know about guidelines-A mixed-method analysis of guideline implementation in Dutch hospitals.

PubMed

Blume, Louise H K; van Weert, Nico J H W; Busari, Jamiu O; Stoopendaal, Annemiek M V; Delnoij, Diana M J

2017-12-01

This study provides insight into how Dutch hospitals ensure that guidelines are used in practice and identifies what key messages other hospitals can learn from existing practices. We examine current practices in handling compliance and, therefore, focus on hospitals that reported that they do not experience problems in the implementation of guidelines. A survey of Dutch hospital boards and 9 semistructured interviews were conducted with a purposive sample of 3 hospitals. Interviews were held with 3 representatives of each hospital, specifically, with a member of the board of directors, a member of the executive medical staff, and the manager of the quality and safety department. Hospitals find guidelines necessary and useful. Hospitals have the power to improve implementation if boards of directors and medical staff are committed, intrinsically motivated, cooperate with each other, and use guidelines pragmatically. Even then, they prioritize guidelines, as resources are scarce. Despite their good work, all hospitals in this study appeared to struggle to adhere to guidelines. If hospitals experience problems with guideline implementation, they tend to focus more on external expectations, leading to defensive behaviour. Hospitals that do not experience implementation problems focus more on integrating guidelines into their own policies. © 2017 John Wiley & Sons, Ltd.

Benchmarking progress in the implementation of the Fourth Joint Societies' Task Force Guidelines on the Prevention of Cardiovascular Disease in Clinical Practice.

PubMed

Morgan, Karen; Burke, Helen; McGee, Hannah

2013-02-01

The Fourth Joint Societies' Task Force (4th JTF) Guidelines on Cardiovascular Disease Prevention in Clinical Practice are agreed, evidence-based standards of care across European countries and professions. In advance of the publication of the 5th JTF Guidelines in 2012, this work assesses the extent to which the 4th JTF guidelines have been implemented. Qualitative study of guideline implementation in 13 European countries, focusing on the themes of guideline implementation structures, processes, and outcomes. Key personnel in 13 selected countries completed interviews or comparable questionnaires: they were national coordinators for CVD prevention (n = 14) and representatives of the national cardiac society (n = 9), heart foundations (n = 11), health ministry (n = 8), and service providers (n = 3). Interview and service-related data from each country were compiled to provide a detailed overview. Ten of the 13 countries used European Society of Cardiology (ESC) guidelines on prevention at a national level, where three broad approaches to implementation were identified. In all 10 countries, multidisciplinary alliances oversaw implementation, but ongoing promotion of the guidelines was not evident, with just two of the 10 countries conducting evaluation of implementation. Barriers to implementation included weak health authority support, the unwieldy nature of the guidelines, guideline fatigue, and the lesser role of prevention in national healthcare systems. Substantial progress had been made in implementing the guidelines, but countries struggled with the task. Some rebalancing of the ESC focus may be warranted so that part of the effort dedicated to improving guidelines might be redirected at translating them into practice.

Empowering nurses to handle the guideline implementation process: identification of implementation competencies.

PubMed

Holleman, Gerda; van Tol, Marjo; Schoonhoven, Lisette; Mintjes-de Groot, Joke; van Achterberg, Theo

2014-01-01

Employing nurses as opinion leaders to implement guidelines may be a promising implementation activity. Until now, insight into necessary competencies of nurse opinion leaders is lacking. We studied and supported aspiring nurse opinion leaders, using a training program based on social influence and implementation theory. Twenty-one competencies were identified, of which the most important were cooperating, communicating, delegating, giving feedback, networking, and information processing. Understanding and addressing these competencies may support the implementation of evidence-based guidelines.

The development of a guideline implementability tool (GUIDE-IT): a qualitative study of family physician perspectives

PubMed Central

2014-01-01

Background The potential of clinical practice guidelines has not been realized due to inconsistent adoption in clinical practice. Optimising intrinsic characteristics of guidelines (e.g., its wording and format) that are associated with uptake (as perceived by their end users) may have potential. Using findings from a realist review on guideline uptake and consultation with experts in guideline development, we designed a conceptual version of a future tool called Guideline Implementability Tool (GUIDE-IT). The tool will aim to involve family physicians in the guideline development process by providing a process to assess draft guideline recommendations. This feedback will then be given back to developers to consider when finalizing the recommendations. As guideline characteristics are best assessed by end-users, the objectives of the current study were to explore how family physicians perceive guideline implementability, and to determine what components should comprise the final GUIDE-IT prototype. Methods We conducted a qualitative study with family physicians inToronto, Ontario. Two experienced investigators conducted one-hour interviews with family physicians using a semi-structured interview guide to 1) elicit feedback on perceptions on guideline implementability; 2) to generate a discussion in response to three draft recommendations; and 3) to provide feedback on the conceptual GUIDE-IT. Sessions were audio taped and transcribed verbatim. Data collection and analysis were guided by content analyses. Results 20 family physicians participated. They perceived guideline uptake according to facilitators and barriers across 6 categories of guideline implementability (format, content, language, usability, development, and the practice environment). Participants’ feedback on 3 draft guideline recommendations were grouped according to guideline perception, cognition, and agreement. When asked to comment on GUIDE-IT, most respondents believed that the tool would be useful, but urged to involve “regular” or community family physicians in the process, and suggested that an online system would be the most efficient way to deliver it. Conclusions Our study identified facilitators and barriers of guideline implementability from the perspective of community and academic family physicians that will be used to build our GUIDE-IT prototype. Our findings build on current knowledge by showing that family physicians perceive guideline uptake mostly according to factors that are in the control of guideline developers. PMID:24476491

[Lessons learned from the implementation of Dutch national healthcare guidelines on childhood obesity].

PubMed

Schalkwijk, A A H; Nijpels, G; Bot, S D M; Chin A Paw, M J M; Renders, C M; Elders, P J M

2016-01-01

To describe the implementation and feasibility of the national healthcare guidelines on childhood obesity in a region with a high prevalence of overweight and obesity in children. Descriptive, implementation study. The implementation of the guidelines took place in the borough Amsterdam West. In total, 17 general practitioners (GP) from the Academic General Practice Network (ANH) of the VU University Medical Center, Amsterdam, participated in the study, along with 19 child healthcare practitioners and 3 paediatricians. A number of measures were taken to promote implementation. Feasibility was evaluated using both qualitative and quantitative methods. The participating healthcare providers found the training in application of the guidelines and case study discussions useful. GPs found that their role as central caregiver was not feasible. All participants expressed a preference for child healthcare practitioners as the central caregiver. A total of 327 obese children were invited to attend the GP's surgery; only 65 of them participated in the study and only 28 children were monitored for a whole year. Collaboration agreements between involved healthcare providers were rarely fulfilled. Implementation of the national healthcare guidelines on childhood obesity in the current form appears not to be feasible in Amsterdam West, despite the many implementation-enhancing measures that were applied. It is questionable whether the national healthcare guidelines on childhood obesity in its current form can contribute to addressing the societal problem of overweight and obesity in children.

Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP).

PubMed

McKee, Gabrielle; Kerins, Mary; Hamilton, Glenys; Hansen, Tina; Hendriks, Jeroen; Kletsiou, Eleni; Lambrinou, Ekaterini; Jennings, Catriona; Fitzsimons, Donna

2017-12-01

The European Society of Cardiology (ESC) has a comprehensive clinical guideline development programme, relevant for all clinicians. However, implementation of guidelines is not always optimal. The aim of this study was to determine nurses' and allied professionals' awareness and barriers regarding clinical guideline implementation. A cross-sectional survey was administrated online and in print at EuroHeartCare 2015. A questionnaire was developed which examined awareness and barriers to implementation of ESC guidelines on cardiovascular disease prevention in clinical practice (2012) and ESC guidelines in general. Of the 298 respondents, 12% reported that the prevention guidelines were used in their practice area. Respondents identified, in order of magnitude, that lack of leadership, workload, time, resources and a perception that they were unable to influence current practice were barriers to the use of the prevention guidelines. When asked to rank barriers to use of any ESC guidelines, time (22%) and leadership (23%) were ranked highest. Implementation of ESC guidelines by nurses, the majority responders in this survey, is a serious problem, requiring urgent improvement to ensure patients receive optimal evidence based care. Issues of leadership, workload, time and resources are significant barriers to guideline implementation. It is of concern that these professionals perceive both that they have little influence on implementation decisions and lack of leadership regarding guideline implementation. Educational and organisational strategies to improve leadership skills are imperative. These will build self-efficacy and empower nurses and allied professionals to advocate for evidence-based care in the clinical environment.

Practice guidelines need to address the 'how' and the 'what' of implementation.

PubMed

McKillop, Ann; Crisp, Jackie; Walsh, Kenneth

2012-01-01

The aim of this study was to explore the realities of everyday nursing practice associated with the implementation of a guideline for the assessment and management of cardiovascular risk. The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable and, in spite of much investigation, remains resistant to explanation of what works and why. Exploration of the nature of guideline implementation has the potential to illuminate the complexities of guideline implementation by focussing on the nature of practice. Nurses are well placed at the front line of primary health care to contribute to an understanding of how guideline implementation plays out in their everyday practice. Qualitative description was used, involving focus groups and interviews with 32 participants (20 nurses, four doctors, five managers and three funder/planners), to explore the use of a guideline in everyday primary health-care practice. Thematic analysis of data was managed through an inductive process of familiarisation, coding, categorising and generation of themes. Four themes were generated from the data portraying the realities of guideline implementation for primary health-care nurses: self-managing patient, everyday nursing practice, developing new relationships in the health team and impact on health-care delivery. The findings reveal that, even with the best of intentions to implement the guideline, health professionals were frustrated and at a loss as to how to achieve that in practice. Consequently, cardiovascular risk assessment and management was uneven and fragmented. Primary health-care practice environments vary so much that solutions to the difficulties of implementing evidence into practice requires context-specific solution-finding through collaborative teamwork. Furthermore, the attention of guideline developers, health-care policymakers, funders and researchers requires direct focus on the 'how' and the 'what' of evidence implementation.

Implementation of community-acquired pneumonia guidelines at a public hospital in Brazil.

PubMed

Conterno, Lucieni Oliveira; Moraes, Fábio Ynoe de; Silva Filho, Carlos Rodrigues da

2011-01-01

To implement community-acquired pneumonia (CAP) guidelines at a public hospital in Brazil and to evaluate the impact of these guidelines on health care quality. A quasi-experimental study, with a before-and-after design, involving adult patients diagnosed with CAP and hospitalized between July of 2007 and October of 2008 in the general ward of the Marília School of Medicine Hospital das Clínicas, located in the city of Marília, Brazil. During the study period, 68 patients were diagnosed with CAP: 48 before the implementation of the guidelines and 20 after their implementation. After the implementation of the guidelines, 85% of the cases were treated in accordance with the guidelines, and there was a significant increase in the use of antibiotic therapy for atypical bacteria in patients with severe CAP (6.3% vs. 75.0%; p < 0.001). Comparing the pre-implementation and post-implementation periods, we observed a trend toward a decrease in the mortality (35.4% vs. 15.0%; p = 0.09) and toward an increase in the recording of SpO₂ in the medical charts of the patients (18% vs. 30%; p = 0.42). During the study period, the degree of severity was not recorded on the medical charts of most patients. In addition, the initiation of antibiotic therapy followed a pre-established schedule, regardless of the severity of the infection. This study showed that, although the development and implementation of CAP guidelines promoted the optimization of the treatment, there were no significant differences regarding the assessment of severity, SpO₂ recording, or the initiation of antibiotic therapy. Therefore, strategies that are more effective are needed in order to modify variables related to the work of physicians and nurses.

Implementing clinical guidelines in stroke: a qualitative study of perceived facilitators and barriers.

PubMed

Donnellan, Claire; Sweetman, S; Shelley, E

2013-08-01

Clinical guidelines are frequently used as a mechanism for implementing evidence-based practice. However research indicates that health professionals vary in the extent to which they adhere to these guidelines. This study aimed to study the perceptions of stakeholders and health professionals on the facilitators and barriers to implementing national stroke guidelines in Ireland. Qualitative interviews using focus groups were conducted with stakeholders (n=3) and multidisciplinary team members from hospitals involved in stroke care (n=7). All focus group interviews were semi-structured, using open-ended questions. Data was managed and analysed using NVivo 9 software. The main themes to emerge from the focus groups with stakeholders and hospital multidisciplinary teams were very similar in terms of topics discussed. These were resources, national stroke guidelines as a tool for change, characteristics of national stroke guidelines, advocacy at local level and community stroke care challenges. Facilitators perceived by stakeholders and health professionals included having dedicated resources, user-friendly guidelines relevant at local level and having supportive advocates on the ground. Barriers were inadequate resources, poor guideline characteristics and insufficient training and education. This study highlights health professionals' perspectives regarding many key concepts which may affect the implementation of stroke care guidelines. The introduction of stroke clinical guidelines at a national level is not sufficient to improve health care quality as they should be incorporated in a quality assurance cycle with education programmes and feedback from surveys of clinical practice. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Implementation of Pharmaceutical Practice Guidelines by a Project Model Based

PubMed Central

Mahmoudi, Laleh; Karamikhah, Razieh; Mahdavinia, Azadeh; Samiei, Hasan; Petramfar, Peyman; Niknam, Ramin

2015-01-01

Abstract All around the world a few studies have been found on the effect of guideline implementation on direct medications’ expenditure. The goal of this study was to evaluate cost savings of guideline implementation among patients who had to receive 3 costly medications including albumin, enoxaparin, and pantoprazole in a tertiary hospital in Shiraz, Iran. An 8-month prospective study was performed in 2 groups; group 1 as an observational group (control group) in 4 months from June to September 2014 and group 2 as an interventional group from October 2014 to January 2015. For group 1 the pattern of costly medications usage was determined without any intervention. For group 2, after guideline implementation, the economic impact was evaluated by making comparisons between the data achieved from the 2 groups. A total of 12,680 patients were evaluated during this study (6470 in group 1; 6210 in group 2). The reduction in the total value of costly administered drugs was 56% after guideline implementation. Such reduction in inappropriate prescribing accounts for the saving of 85,625 United States dollars (USD) monthly and estimated 1,027,500 USD annually. Guideline implementation could improve the adherence of evidence-based drug utilization and resulted in significant cost savings in a major teaching medical center via a decrease in inappropriate prescribing of costly medications. PMID:26496288

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial.

PubMed

Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming; Maindal, Helle Terkildsen; Petersen, Karin Dam; Jensen, Martin Bach

2013-10-20

Evidence-based clinical practice guidelines may improve treatment quality, but the uptake of guideline recommendations is often incomplete and slow. Recently new low back pain guidelines are being launched in Denmark. The guidelines are considered to reduce personal and public costs. The aim of this study is to evaluate whether a complex, multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy. In a two-armed cluster randomised trial, 100 general practices (clusters) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included. Practices are randomly allocated 1:1 to a simple or a complex implementation strategy. Intervention practices will receive a complex implementation strategy, including guideline facilitator visits, stratification tools, and quality reports on low back pain treatment. Primary outcome is referral to secondary care. Secondary outcomes are pain, physical function, health-related quality of life, patient satisfaction with care and treatment outcome, employment status, and sick leave. Primary and secondary outcomes pertain to the patient level. Assessments of outcomes are blinded and follow the intention-to-treat principle. Additionally, a process assessment will evaluate the degree to which the intervention elements will be delivered as planned, as well as measure changes in beliefs and behaviours among general practitioners and patients. This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice, and will provide insight on essential elements to include in future implementation strategies in general practice. Registered as NCT01699256 on ClinicalTrials.gov.

Case Studies - Creating a Digital Marketspace Presence: Lessons in Extranet Implementation.

ERIC Educational Resources Information Center

Angeles, Rebecca

2001-01-01

This study seeks a practical understanding of the business, organizational, and technical components of and implementation guidelines needed to effectively deploy extranets. It aims to establish a basic conceptual framework for understanding extranet implementation guidelines. Provides a specific case using VF Playwear, Inc.'s HealthTexbtob.com, a…

Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review

PubMed Central

2009-01-01

Background Electronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services. Methods A systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two). Results Twenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two). Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care. PMID:20042070

Implementation of concussion guidelines in community Australian Football and Rugby League-The experiences and challenges faced by coaches and sports trainers.

PubMed

Kemp, Joanne L; Newton, Joshua D; White, Peta E; Finch, Caroline F

2016-04-01

While guidelines outlining the appropriate management of sport-related concussion have been developed and adapted for use within community sport, it remains unknown how they are experienced by those responsible for implementing them. Longitudinal study. 111 coaches and sports trainers from community-level Australian Football and Rugby League teams completed pre- and post-season surveys assessing their attitudes towards using concussion guidelines. Participants also provided post-season feedback regarding their experiences in using the guidelines. 71% of participants reported using the guidelines in the preceding season. Post-season attitude was related to pre-season attitude (p=0.002), football code (p=0.015), and team role (p=0.045). An interaction between team role and guideline use (p=0.012) was also found, with coaches who had used the guidelines, and sports trainers who had not, reporting more positive post-season attitudes towards using the concussion guidelines. Implementation challenges included disputing of decisions about return-to-play by players, parents, and coaches, and a perceived lack of time. Recommendations for improved guideline materials included using larger fonts and providing for witnessing of advice given to players. This is the first study to examine the implementation of concussion guidelines in community sport. Training of coaches/sports trainers needs enhancement. In addition, new education should be developed for parents/players about the importance of the return-to-play advice given to them by those who follow these guidelines. Information provided by those who attempted to use the guidelines will assist the refinement of implementation and dissemination processes around concussion guidelines across sports. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Implementing healthier foodservice guidelines in hospital and federal worksite cafeterias: barriers, facilitators and keys to success.

PubMed

Jilcott Pitts, S B; Graham, J; Mojica, A; Stewart, L; Walter, M; Schille, C; McGinty, J; Pearsall, M; Whitt, O; Mihas, P; Bradley, A; Simon, C

2016-12-01

Healthy foodservice guidelines are being implemented in worksites and healthcare facilities to increase access to healthy foods by employees and public populations. However, little is known about the barriers to and facilitators of implementation. The present study aimed to examine barriers to and facilitators of implementation of healthy foodservice guidelines in federal worksite and hospital cafeterias. Using a mixed-methods approach, including a quantitative survey followed by a qualitative, in-depth interview, we examined: (i) barriers to and facilitators of implementation; (ii) behavioural design strategies used to promote healthier foods and beverages; and (iii) how implementation of healthy foodservice guidelines influenced costs and profitability. We used a purposive sample of five hospital and four federal worksite foodservice operators who recently implemented one of two foodservice guidelines: the United States Department of Health and Human Services/General Services Administration Health and Sustainability Guidelines ('Guidelines') in federal worksites or the Partnership for a Healthier America Hospital Healthier Food Initiative ('Initiative') in hospitals. Descriptive statistics were used to analyse quantitative survey data. Qualitative data were analysed using a deductive approach. Implementation facilitators included leadership support, adequate vendor selections and having dietitians assist with implementation. Implementation barriers included inadequate selections from vendors, customer complaints and additional expertise required for menu labelling. Behavioural design strategies used most frequently included icons denoting healthier options, marketing using social media and placement of healthier options in prime locations. Lessons learned can guide subsequent steps for future healthy foodservice guideline implementation in similar settings. © 2016 The British Dietetic Association Ltd.

Guideline adaptation and implementation planning: a prospective observational study

PubMed Central

2013-01-01

Background Adaptation of high-quality practice guidelines for local use has been advanced as an efficient means to improve acceptability and applicability of evidence-informed care. In a pan-Canadian study, we examined how cancer care groups adapted pre-existing guidelines to their unique context and began implementation planning. Methods Using a mixed-methods, case-study design, five cases were purposefully sampled from self-identified groups and followed as they used a structured method and resources for guideline adaptation. Cases received the ADAPTE Collaboration toolkit, facilitation, methodological and logistical support, resources and assistance as required. Documentary and primary data collection methods captured individual case experience, including monthly summaries of meeting and field notes, email/telephone correspondence, and project records. Site visits, process audits, interviews, and a final evaluation forum with all cases contributed to a comprehensive account of participant experience. Results Study cases took 12 to >24 months to complete guideline adaptation. Although participants appreciated the structure, most found the ADAPTE method complex and lacking practical aspects. They needed assistance establishing individual guideline mandate and infrastructure, articulating health questions, executing search strategies, appraising evidence, and achieving consensus. Facilitation was described as a multi-faceted process, a team effort, and an essential ingredient for guideline adaptation. While front-line care providers implicitly identified implementation issues during adaptation, they identified a need to add an explicit implementation planning component. Conclusions Guideline adaptation is a positive initial step toward evidence-informed care, but adaptation (vs. ‘de novo’ development) did not meet expectations for reducing time or resource commitments. Undertaking adaptation is as much about the process (engagement and capacity building) as it is about the product (adapted guideline). To adequately address local concerns, cases found it necessary to also search and appraise primary studies, resulting in hybrid (adaptation plus de novo) guideline development strategies that required advanced methodological skills. Adaptation was found to be an action element in the knowledge translation continuum that required integration of an implementation perspective. Accordingly, the adaptation methodology and resources were reformulated and substantially augmented to provide practical assistance to groups not supported by a dedicated guideline panel and to provide more implementation planning support. The resulting framework is called CAN-IMPLEMENT. PMID:23656884

How GPs implement clinical guidelines in everyday clinical practice--a qualitative interview study.

PubMed

Le, Jette V; Hansen, Helle P; Riisgaard, Helle; Lykkegaard, Jesper; Nexøe, Jørgen; Bro, Flemming; Søndergaard, Jens

2015-12-01

Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP's decision on whether and how to manage implementation. Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

An economic analysis of implementing the SIGN third molar guideline: implications for the design and analysis of implementation studies.

PubMed

Tilley, Colin; McIntosh, Emma; Bahrami, Maryam; Clarkson, Jan; Deery, Chris; Pitts, Nigel

2005-07-01

To compare the cost-effectiveness of four third molar guideline implementation strategies. Fifty-one dental practices in Scotland were randomized to one of four implementation strategies. The effectiveness of the strategies was measured by general dental practitioners' compliance with the guideline. The effectiveness of the guideline depended crucially upon the type of patient treated. In particular, for a minority of patients (14%) with no clinical signals of their 'type', the implementation strategies generate potentially large gains in evidence-based practice. However, the cost per patient of achieving these gains is large given that the costs are incurred for all patients, but benefits accrue only to a minority. The results show that the type of patient presenting for treatment can influence the effectiveness, cost-effectiveness and therefore policy conclusions. Consequently, the design and analysis of studies need to be sufficiently sensitive to detect subtle interaction effects. This may explain the dearth of guideline implementation trials with significant findings. The results also suggest that a more cost-effective implementation method in primary care dentistry may be to subsidize treatment conditional upon patient type.

Implementation of treatment guidelines for specialist mental health care.

PubMed

Bighelli, Irene; Ostuzzi, Giovanni; Girlanda, Francesca; Cipriani, Andrea; Becker, Thomas; Koesters, Markus; Barbui, Corrado

2016-12-15

A huge gap exists between the production of evidence and its uptake in clinical practice settings. To fill this gap, treatment guidelines, based on explicit assessments of the evidence base, are commonly used in several fields of psychiatry, including schizophrenia and related psychotic disorders. However, it remains unclear whether treatment guidelines have any material impact on provider performance and patient outcomes, and how implementation should be conducted to maximise benefit. The primary objective of this review was to examine the efficacy of guideline implementation strategies in improving process outcomes (performance of healthcare providers) and patient outcomes. We also explored which components of different guideline implementation strategies could influence them. We searched the Cochrane Schizophrenia Group Register (March 2012 and August 2015), as well as references of included studies. Studies that examined schizophrenia-spectrum disorders to compare guideline implementation strategies with usual care or to assess the comparative efficacy of different guideline implementation strategies. Review authors worked independently and in duplicate to critically appraise records from 990 studies; six individual studies met the inclusion criteria. Among the six included studies, significant heterogeneity was found in the focus of the guideline, target of the intervention, implementation strategy, and outcome measures, so meta-analysis was carried out for antipsychotic co-prescribing only. This review now includes six studies, with a total of 1727 participants. Of the six included studies, practitioner impact was assessed in four. Overall, risk of bias was rated as low or unclear, and all evidence in the 'Summary of findings' tables was graded as low or very low quality. Meta-analysis revealed that a combination of several guideline dissemination and implementation strategies targeting healthcare professionals did not reduce antipsychotic co-prescribing in schizophrenia outpatients (2 RCTs, N = 1082, RR 1.10 CI 0.99 to 1.23; corrected for cluster design: N = 310, RR 0.97, CI 0.75 to 1.25, very low-quality evidence). One trial, which studied a nurse-led intervention aimed at promoting cardiovascular disease screening, found a significant effect in the proportion of people receiving screening (Framingham score: N = 110, RR 0.69, 95% CI 0.55 to 0.87), although in the analysis corrected for cluster design, the effect was no longer statistically significant (N = 38, RR 0.71, 95% CI 0.48 to 1.03, very low-quality evidence).One trial reported the patient outcomes of global state, satisfaction with care, treatment adherence, and drug attitude; no effect between treatments was seen. Quality of life was not reported by any of the studies.One trial, which studied the use of re-written guideline text compared to original text, did not find a significant effect on staff receiving training (N = 68, RR 1.03, 95% CI 0.87 to 1.21, low-quality evidence), staff receiving supervision (N = 68, RR 0.86, 95% CI 0.64 to 1.17, low-quality evidence), or staff providing psychological interventions (N = 68, RR 0.86, 95% CI 0.62 to 1.18, low-quality evidence).Regarding participant outcomes, only one trial assessed the efficacy of a shared decision-making implementation strategy and found no impact on psychopathology, satisfaction with care, or drug attitude. Another single trial studied a multifaceted intervention to promote medication adherence and found no effect on adherence rates. Considering the available evidence, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that uncertainty remains about clinically meaningful and sustainable effects of treatment guidelines on patient outcomes and how best to implement such guidelines for maximal benefit.

Do guidelines offer implementation advice to target users? A systematic review of guideline applicability.

PubMed

Gagliardi, Anna R; Brouwers, Melissa C

2015-02-18

Providers and patients are most likely to use and benefit from guidelines accompanied by implementation support. Guidelines published in 2007 and earlier assessed with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument scored poorly for applicability, which reflects the inclusion of implementation instructions or tools. The purpose of this study was to examine the applicability of guidelines published in 2008 or later and identify factors associated with applicability. Systematic review of studies that used AGREE to assess guidelines published in 2008 or later. MEDLINE and EMBASE were searched from 2008 to July 2014, and the reference lists of eligible items. Two individuals independently screened results for English language studies that reviewed guidelines using AGREE and reported all domain scores, and extracted data. Descriptive statistics were calculated across all domains. Multilevel regression analysis with a mixed effects model identified factors associated with applicability. Of 245 search results, 53 were retrieved as potentially relevant and 20 studies were eligible for review. The mean and median domain scores for applicability across 137 guidelines published in 2008 or later were 43.6% and 42.0% (IQR 21.8-63.0%), respectively. Applicability scored lower than all other domains, and did not markedly improve compared with guidelines published in 2007 or earlier. Country (UK) and type of developer (disease-specific foundation, non-profit healthcare system) appeared to be associated with applicability when assessed with AGREE II (not original AGREE). Despite increasing recognition of the need for implementation tools, guidelines continue to lack such resources. To improve healthcare delivery and associated outcomes, further research is needed to establish the type of implementation tools needed and desired by healthcare providers and consumers, and methods for developing high-quality tools. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Implementation plans included in World Health Organisation guidelines.

PubMed

Wang, Zhicheng; Norris, Susan L; Bero, Lisa

2016-05-20

The implementation of high-quality guidelines is essential to improve clinical practice and public health. The World Health Organisation (WHO) develops evidence-based public health and other guidelines that are used or adapted by countries around the world. Detailed implementation plans are often necessary for local policymakers to properly use the guidelines developed by WHO. This paper describes the plans for guideline implementation reported in WHO guidelines and indicates which of these plans are evidence-based. We conducted a content analysis of the implementation sections of WHO guidelines approved by the WHO guideline review committee between December 2007 and May 2015. The implementation techniques reported in each guideline were coded according to the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) taxonomy and classified as passive, active or policy strategies. The frequencies of implementation techniques are reported. The WHO guidelines (n = 123) analysed mentioned implementation techniques 800 times, although most mentioned implementation techniques very briefly, if at all. Passive strategies (21 %, 167/800) and general policy strategies (62 %, 496/800) occurred most often. Evidence-based active implementation methods were generally neglected with no guideline mentioning reminders (computerised or paper) and only one mentioning a multifaceted approach. Many guidelines contained implementation sections that were identical to those used in older guidelines produced by the same WHO technical unit. The prevalence of passive and policy-based implementation techniques as opposed to evidence-based active techniques suggests that WHO guidelines should contain stronger guidance for implementation. This could include structured and increased detail on implementation considerations, accompanying or linked documents that provide information on what is needed to contextualise or adapt a guideline and specific options from among evidence-based implementation strategies.

[Evaluation of hospital admissions: admission guidelines implementation in a pediatric emergency department].

PubMed

Katz, Manuel; Warshawsky, Sheila S; Rosen, Shirley; Barak, Nurit; Press, Joseph

2004-10-01

To develop and implement locally tailored pediatric admission guidelines for use in a pediatric emergency department and evaluate the appropriateness of admissions based on these guidelines. Our Study was based on the development of admission guidelines by senior physicians, using the Delphi Consensus Process, for use in the Pediatric Emergency Department (PED) at Soroka University Medical Center (Soroka). We evaluated the appropriateness of admissions to the pediatric departments of Soroka on 33 randomly selected days in 1999 and 2000 prior to guideline implementation and 30 randomly selected days in 2001, after guideline implementation. A total of 1037 files were evaluated. A rate of 12.4% inappropriate admissions to the pediatric departments was found based on locally tailored admission guidelines. There was no change in the rate of inappropriate admissions after implementation of admission guidelines in PED. Inappropriate admissions were associated with age above 3 years, hospital stay of two days or less and the season. The main reasons for evaluating an admission as inappropriate were that the admission did not comply with the guidelines and that the case could be managed in an ambulatory setting. There were distinctive differences in the characteristics of the Bedouin and Jewish populations admitted to the pediatric departments, although no difference was found in the rate of inappropriate admissions between these populations. Patient management in Soroka PED is tailored to the conditions of this medical center and to the characteristics of the population it serves. The admission guidelines developed reflect these special conditions. Lack of change in the rate of inappropriate admissions following implementation of the guidelines indicates that the guidelines reflect the physicians' approach to patient management that existed in Soroka PED prior to guideline implementation. Hospital admission guidelines have a role in the health management system; however, these guidelines must be tailored to reflect local characteristics and needs.

Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates

PubMed Central

Larson, Elaine L.; Quiros, Dave; Lin, Susan X.

2007-01-01

Background The diffusion of national evidence-based practice guidelines and their impact on patient outcomes often go unmeasured. Methods Our objectives were to (1) evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention (CDC) Hand Hygiene Guideline, (2) compare rates of health care-associated infections (HAI) before and after implementation of the Guideline recommendations, and (3) examine the patterns and correlates of changes in rates of HAI. We used pre- and post-Guideline implementation site visits and surveys in the setting of 40 US hospitals—members of the National Nosocomial Infections Surveillance System—and measured HAI rates 1 year before and after publication of the CDC Guideline and used direct observation of hand hygiene compliance and Guideline implementation scores. Results All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8% of 1359 staff members surveyed anonymously reported that they were familiar with the Guideline. However, in 44.2% of the hospitals (19/40), there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (mean, 56.6%). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene (P < .001). No impact of Guideline implementation or hand hygiene compliance on other HAI rates was identified. Other factors occurring over time could affect rates of HAI. Observed hand hygiene compliance rates were likely to overestimate rates in actual practice. The study may have been of too short duration to detect the impact of a practice guideline. Conclusion Wide dissemination of this Guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support. PMID:18063132

Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates.

PubMed

Larson, Elaine L; Quiros, Dave; Lin, Susan X

2007-12-01

The diffusion of national evidence-based practice guidelines and their impact on patient outcomes often go unmeasured. Our objectives were to (1) evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention (CDC) Hand Hygiene Guideline, (2) compare rates of health care-associated infections (HAI) before and after implementation of the Guideline recommendations, and (3) examine the patterns and correlates of changes in rates of HAI. We used pre- and post-Guideline implementation site visits and surveys in the setting of 40 US hospitals--members of the National Nosocomial Infections Surveillance System--and measured HAI rates 1 year before and after publication of the CDC Guideline and used direct observation of hand hygiene compliance and Guideline implementation scores. All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8% of 1359 staff members surveyed anonymously reported that they were familiar with the Guideline. However, in 44.2% of the hospitals (19/40), there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (mean, 56.6%). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene (P < .001). No impact of Guideline implementation or hand hygiene compliance on other HAI rates was identified. Other factors occurring over time could affect rates of HAI. Observed hand hygiene compliance rates were likely to overestimate rates in actual practice. The study may have been of too short duration to detect the impact of a practice guideline. Wide dissemination of this Guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.

Effectiveness of multifaceted implementation strategies for the implementation of back and neck pain guidelines in health care: a systematic review.

PubMed

Suman, Arnela; Dikkers, Marije F; Schaafsma, Frederieke G; van Tulder, Maurits W; Anema, Johannes R

2016-09-20

For the optimal use of clinical guidelines in daily practice, mere distribution of guidelines and materials is not enough, and active implementation is needed. This review investigated the effectiveness of multifaceted implementation strategies compared to minimal, single, or no implementation strategy for the implementation of non-specific low back and/or neck pain guidelines in health care. The following electronic databases were searched from inception to June 1, 2015: MEDLINE, Embase, PsycInfo, the Cochrane Library, and CINAHL. The search strategy was restricted to low back pain, neck pain, and implementation research. Studies were included if their design was a randomized controlled trial, reporting on patients (age ≥18 years) with non-specific low back pain or neck pain (with or without radiating pain). Trials were eligible if they reported patient outcomes, measures of healthcare professional behaviour, and/or outcomes on healthcare level. The primary outcome was professional behaviour. Guidelines that were evaluated in the studies had to be implemented in a healthcare setting. No language restrictions were applied, and studies had to be published full-text in peer-reviewed journals, thus excluding abstract only publications, conference abstracts, and dissertation articles. Two researchers independently screened titles and abstract, extracted data from included studies, and performed risk of bias assessments. After removal of duplicates, the search resulted in 4750 abstracts to be screened. Of 43 full-text articles assessed for eligibility, 12 were included in this review, reporting on 9 individual studies, and separate cost-effectiveness analyses of 3 included studies. Implementation strategies varied between studies. Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls. This review showed that multifaceted strategies for the implementation of neck and/or back pain guidelines in health care do not significantly improve professional behaviour outcomes. No effects on patient outcomes or cost of care could be found. More research is necessary to determine whether multifaceted implementation strategies are conducted as planned and whether these strategies are effective in changing professional behaviour and thereby clinical practice.

10 CFR 960.3 - Implementation guidelines.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 10 Energy 4 2013-01-01 2013-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...

10 CFR 960.3 - Implementation guidelines.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 10 Energy 4 2012-01-01 2012-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...

10 CFR 960.3 - Implementation guidelines.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 10 Energy 4 2014-01-01 2014-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...

10 CFR 960.3 - Implementation guidelines.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 10 Energy 4 2011-01-01 2011-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...

10 CFR 960.3 - Implementation guidelines.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 10 Energy 4 2010-01-01 2010-01-01 false Implementation guidelines. 960.3 Section 960.3 Energy DEPARTMENT OF ENERGY GENERAL GUIDELINES FOR THE PRELIMINARY SCREENING OF POTENTIAL SITES FOR A NUCLEAR WASTE REPOSITORY Implementation Guidelines § 960.3 Implementation guidelines. The guidelines of this subpart...

[Impact of low-molecular-weight heparin practice guidelines in a geriatric hospital].

PubMed

d'Arailh, Lydie; Gaubert-Dahan, Marie-Line; Muller, Florence; Lechowski, Laurent; Teillet, Laurent

2011-06-01

The purpose of this study was to assess the impact of good use of anticoagulants guidelines implementation on low molecular weight heparin (LMWH) prescription in a french geriatric hospital. This interventional "before and after" study was conduced by the same geriatrician on a d-day in 2006 and 2009. Guidelines for anticoagulant's prescription based on selected references in the literature was established by an expert's consensus and implemented in 2008. Data were collected in all departments at the Sainte-Perine geriatric hospital for each patient with an LMWH prescription. Assessment was based on quality judgment criteria (indication, dosage, treatment duration, biological monitoring of LMWH). Data were collected for 72 prescriptions prior to the guidelines implementation and for 54 after. Sex-ratio, mean age and percentage of LMWH prescription did not differ significantly between the two periods. There was a better conformity for LMWH dosage prescription (p = 0.002) and biological monitoring prescription (p = 0.036) after the guidelines implementation. Conformity of LMWH indication and treatment duration were improved but the difference remained not significant (respectively p = 0.49 and p = 0.80). Implementing guidelines for LMWH use in geriatrics can improve quality of prescription. The impact was effective but limited. These guidelines are now in general use in the Sainte-Perine hospital.

Developing a questionnaire to identify perceived barriers for implementing the Dutch physical therapy COPD clinical practice guideline.

PubMed

van der Wees, Philip J; Zagers, Cor A M; de Die, Sara E; Hendriks, Erik J M; Nijhuis-van der Sanden, Maria W G; de Bie, Rob A

2013-05-01

Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation planning. This study aimed at developing a questionnaire to identify perceived barriers for implementing the Dutch COPD guideline for physical therapists and its recommended measurement instruments. An overall questionnaire, based on two existing questionnaires, was constructed to identify barriers and facilitators for implementing the COPD guideline. The construct of the questionnaire was assessed in a cross-sectional study among 246 chest physical therapists. Factor analysis was conducted to explore underlying dimensions. Psychometric properties were analyzed using Cronbach's alpha. Barriers and facilitators were assessed using descriptive statistics. Some 139 physical therapists (57%) responded. Factor analysis revealed 4-factor and 5-factor solutions with an explained variance of 36% and 39% respectively. Cronbach's alpha of the overall questionnaire was 0.90, and varied from 0.66 to 0.92 for the different factors. Underlying domains of the 5-factor solution were characterized as: attitude towards using measurement instruments, knowledge and skills of the physical therapist, applicability of the COPD guideline, required investment of time & money, and patient characteristics. Physical therapists showed a positive attitude toward using the COPD guideline. Main barriers for implementation were required time investment and financial constraints. The construct of the questionnaire revealed relevant underlying domains for the identification of barriers and facilitators for implementing the COPD guideline. The questionnaire allowed for tailoring to the target group and may be used across health care professionals as basis for in-depth analysis of barriers to specific recommendations in guidelines. The results of the questionnaire alone do not provide sufficient information to inform the development of an implementation strategy. The infrastructure for developing the guideline can be used for addressing key barriers by the guideline development group, using the questionnaire as well as in-depth analysis such as focus group interviews. Further development of methods for prospective identification of barriers and consequent tailoring of implementation interventions is required.

Developing a questionnaire to identify perceived barriers for implementing the Dutch physical therapy COPD clinical practice guideline

PubMed Central

2013-01-01

Background Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation planning. This study aimed at developing a questionnaire to identify perceived barriers for implementing the Dutch COPD guideline for physical therapists and its recommended measurement instruments. Methods An overall questionnaire, based on two existing questionnaires, was constructed to identify barriers and facilitators for implementing the COPD guideline. The construct of the questionnaire was assessed in a cross-sectional study among 246 chest physical therapists. Factor analysis was conducted to explore underlying dimensions. Psychometric properties were analyzed using Cronbach’s alpha. Barriers and facilitators were assessed using descriptive statistics. Results Some 139 physical therapists (57%) responded. Factor analysis revealed 4-factor and 5-factor solutions with an explained variance of 36% and 39% respectively. Cronbach’s alpha of the overall questionnaire was 0.90, and varied from 0.66 to 0.92 for the different factors. Underlying domains of the 5-factor solution were characterized as: attitude towards using measurement instruments, knowledge and skills of the physical therapist, applicability of the COPD guideline, required investment of time & money, and patient characteristics. Physical therapists showed a positive attitude toward using the COPD guideline. Main barriers for implementation were required time investment and financial constraints. Conclusions The construct of the questionnaire revealed relevant underlying domains for the identification of barriers and facilitators for implementing the COPD guideline. The questionnaire allowed for tailoring to the target group and may be used across health care professionals as basis for in-depth analysis of barriers to specific recommendations in guidelines. The results of the questionnaire alone do not provide sufficient information to inform the development of an implementation strategy. The infrastructure for developing the guideline can be used for addressing key barriers by the guideline development group, using the questionnaire as well as in-depth analysis such as focus group interviews. Further development of methods for prospective identification of barriers and consequent tailoring of implementation interventions is required. PMID:23631555

Applying the RE-AIM Framework to Evaluate the Dissemination and Implementation of Clinical Practice Guidelines for Sexually Transmitted Infections.

PubMed

Jeong, Heon-Jae; Jo, Heui-Sug; Oh, Moo-Kyung; Oh, Hyung-Won

2015-07-01

Clinical practice guidelines (CPG) are one of the most effective ways to translate evidence of medical improvement into everyday practice. This study evaluated the dissemination and implementation of the Sexually Transmitted Infections-Korean Guidelines (STIKG) by applying the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. A survey questionnaire was administered to clinicians via the internet. Among the 332 respondents, 190 (57.2%) stated that they were aware of STIKG and 107 (33.2%) implemented STIKG in their practice. The odds that a physician was exposed to STIKG (dissemination) were 2.61 times greater among physicians with previous training or education for any CPG than those who did not. Clinicians who indicated that STIKG were easy to understand were 4.88 times more likely to implement STIKG in their practice than those who found them not so easy. When a clinician's workplace had a supporting system for CPG use, the odds of implementation was 3.76 times higher. Perceived level of effectiveness of STIKG did not significantly influence their implementation. The findings of this study suggest that, ultimately, knowing how to engage clinicians in CPG implementation is as important as how to disseminate such guidelines; moreover, easy-to-use guidelines and institutional support are key factors.

Naturalistic study of guideline implementation tool use via evaluation of website access and physician survey.

PubMed

Armstrong, Melissa J; Gronseth, Gary S; Dubinsky, Richard; Potrebic, Sonja; Penfold Murray, Rebecca; Getchius, Thomas S D; Rheaume, Carol; Gagliardi, Anna R

2017-01-13

Clinical guidelines support decision-making at the point-of-care but the onus is often on individual users such as physicians to implement them. Research shows that the inclusion of implementation tools in or with guidelines (GItools) is associated with guideline use. However, there is little research on which GItools best support implementation by individual physicians. The purpose of this study was to investigate naturalistic access and use of GItools produced by the American Academy of Neurology (AAN) to inform future tool development. Website accesses over six months were summarized for eight AAN guidelines and associated GItools published between July 2012 and August 2013. Academy members were surveyed about use of tools accompanying the sport concussion guideline. Data were analyzed using summary statistics and the Chi-square test. The clinician summary was accessed more frequently (29.0%, p < 0.001) compared with the slide presentation (26.8%), patient summary (23.2%) or case study (20.9%), although this varied by guideline topic. For the sport concussion guideline, which was accompanied by a greater variety of GItools, the mobile phone quick reference check application was most frequently accessed, followed by the clinician summary, patient summary, and slide presentation. For the sports concussion guideline survey, most respondents (response rate 21.8%, 168/797) were aware of the guideline (88.1%) and had read the guideline (78.6%). For GItool use, respondents indicated reading the reference card (51.2%), clinician summary (45.2%), patient summary (28.0%), mobile phone application (26.2%), and coach/athletic trainer summary (20.2%). Patterns of sports concussion GItool use were similar between respondents who said they had and had not yet implemented the guideline. Developers faced with resource limitations may wish to prioritize the development of printable or mobile application clinician summaries, which were accessed significantly more than other types of GItools. Further research is needed to understand how to optimize the design of such GItools.

Alliance for a Healthier Generation's competitive beverage and food guidelines: do elementary school administrators know about them and do they report implementing them?

PubMed

Ohri-Vachaspati, Punam; Turner, Lindsey; Chaloupka, Frank J

2012-10-01

The availability of competitive foods in schools is a modifiable factor in efforts to prevent childhood obesity. The Alliance for a Healthier Generation launched the Healthy Schools Program in 2006 to encourage schools to create healthier food environments, including the adoption of nutritional guidelines for competitive beverages and foods. This study examines nationwide awareness and implementation of the guidelines in US public elementary schools. Data were collected from a nationally representative sample of elementary schools using mail-back surveys in 2006-2007, 2007-2008, 2008-2009, and 2009-2010. From 2006-2007 to 2009-2010, awareness of the Alliance's beverage guidelines increased from 35.0% to 51.8% among school administrators (p < .01); awareness of the food guidelines increased from 29.4% to 40.2% (p < .01). By 2009-2010, almost one third of the schools that sold competitive beverages and foods reported having implemented or being in the process of implementing the guidelines. Implementation was higher among schools from Southern states. Schools with a majority of Black or Latino students were less likely to implement the guidelines. Awareness and implementation of the Alliance's beverage and food guidelines has significantly increased since the 2006-2007 school year, indicating successful diffusion of the guidelines. However, many administrators at schools who sold competitive products were not aware of the guidelines, indicating a need for continued efforts. In addition, lower implementation among schools serving minority students suggests that the Alliance's targeted efforts to provide intensive technical assistance to such schools is warranted and necessary. © 2012, American School Health Association.

Pharmacist-led implementation of a vancomycin guideline across medical and surgical units: impact on clinical behavior and therapeutic drug monitoring outcomes

PubMed Central

Phillips, Cameron J; Gordon, David L

2015-01-01

Background Vancomycin is the antibiotic of choice for the treatment of serious infections such as methicillin-resistant Staphylococcus aureus (MRSA). Inappropriate prescribing of vancomycin can lead to therapeutic failure, antibiotic resistance, and drug toxicity. Objective To examine the effectiveness of pharmacist-led implementation of a clinical practice guideline for vancomycin dosing and monitoring in a teaching hospital. Methods An observational pre–post study design was undertaken to evaluate the implementation of the vancomycin guideline. The implementation strategy principally involved education, clinical vignettes, and provision of pocket guidelines to accompany release of the guideline to the hospital Intranet. The target cohort for clinical behavioral change was junior medical officers, as they perform the majority of prescribing and monitoring of vancomycin in hospitals. Assessment measures were recorded for vancomycin prescribing, therapeutic drug monitoring, and patient outcomes. Results Ninety-nine patients, 53 pre- and 46 post-implementation, were included in the study. Prescribing of a loading dose increased from 9% to 28% (P=0.02), and guideline adherence to starting maintenance dosing increased from 53% to 63% (P=0.32). Dose adjustment by doctors when blood concentrations were outside target increased from 53% to 71% (P=0.12), and correct timing of initial concentration measurement increased from 43% to 57% (P=0.23). Appropriately timed trough concentrations improved from 73% to 81% (P=0.08). Pre-dose (trough) concentrations in target range rose from 33% to 44% (P=0.10), while potentially toxic concentrations decreased from 32% to 21% (P=0.05) post-implementation. Infection cure rates for patients increased from 85% to 96% (P=0.11) after the guideline was implemented. Conclusion The implementation strategy employed in this study demonstrated potential effectiveness, and should prompt additional larger studies to optimize strategies that will translate into improved clinical practice using vancomycin. PMID:29354529

Implementing guidelines in nursing homes: a systematic review.

PubMed

Diehl, Heinz; Graverholt, Birgitte; Espehaug, Birgitte; Lund, Hans

2016-07-25

Research on guideline implementation strategies has mostly been conducted in settings which differ significantly from a nursing home setting and its transferability to the nursing home setting is therefore limited. The objective of this study was to systematically review the effects of interventions to improve the implementation of guidelines in nursing homes. A systematic literature search was conducted in the Cochrane Library, CINAHL, Embase, MEDLINE, DARE, HTA, CENTRAL, SveMed + and ISI Web of Science from their inception until August 2015. Reference screening and a citation search were performed. Studies were eligible if they evaluated any type of guideline implementation strategy in a nursing home setting. Eligible study designs were systematic reviews, randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE. Five cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation strategies. One study reported a small statistically significant effect on professional practice, and two studies demonstrated small to moderate statistically significant effects on patient outcome. The overall quality of the evidence for all comparisons was low or very low using GRADE. Little is known about how to improve the implementation of guidelines in nursing homes, and the evidence to support or discourage particular interventions is inconclusive. More implementation research is needed to ensure high quality of care in nursing homes. PROSPERO 2014: CRD42014007664.

Clinical guidelines in the European Union: mapping the regulatory basis, development, quality control, implementation and evaluation across member states.

PubMed

Legido-Quigley, Helena; Panteli, Dimitra; Brusamento, Serena; Knai, Cécile; Saliba, Vanessa; Turk, Eva; Solé, Meritxell; Augustin, Uta; Car, Josip; McKee, Martin; Busse, Reinhard

2012-10-01

Clinical guidelines are advocated to improve the quality of care, especially for chronic diseases. However, the regulatory basis of clinical guidelines, their development, quality control, implementation and use as well as evaluation within countries across the European Union is not systematically known. Using information collected from key informants in each country by means of a structured questionnaire, this mapping exercise illustrates the varied status of guideline production in European Union countries. Most European Union countries have an established national, regional or local clinical guideline programme, and a substantial proportion have developed guidelines on the prevention and management of chronic diseases. Several countries have mechanisms in place to ensure the quality of scientific evidence used for the development of guidelines is high and that the process is consistent and transparent. Others are only now taking an interest in guideline development and are taking the first steps towards establishing ways of implementing them. The majority of countries have no legal basis for the development of guidelines and those that have well established systems mostly implement them on a voluntary basis. The process of guideline development varies in its degrees of decentralisation across countries with many different types of organisations taking on this responsibility. There is general acceptance of the value of the instrument developed by the AGREE collaboration for evaluating the methodological robustness of guidelines. However, the extent to which guidelines are implemented in Europe is unknown, as there is no systematic data collection and, in most countries, no structure to enable it. There are few examples of formal evaluations of the development, quality, implementation and use of guidelines. Our findings call for renewed efforts to respond to the severe lack of standardized guideline terminology and accessibility as well as rigorous studies to evaluate the relationship between different ways to develop guidelines and their methodological quality, between their quality and the actual implementation and usage, and finally between implementation and health outcomes. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Provider Adherence to Implementation of Clinical Practice Guidelines for Neurogenic Bowel in Adults With Spinal Cord Injury

PubMed Central

Goetz, Lance L; Nelson, Audrey L; Guihan, Marylou; Bosshart, Helen T; Harrow, Jeffrey J; Gerhart, Kevin D; Krasnicka, Barbara; Burns, Stephen P

2005-01-01

Background/Objectives: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine Methods: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. Results: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. Conclusions: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management. PMID:16869086

Factors that influence the implementation of dietary guidelines regarding food provision in centre based childcare services: A systematic review.

PubMed

Seward, Kirsty; Finch, Meghan; Yoong, Sze Lin; Wyse, Rebecca; Jones, Jannah; Grady, Alice; Wiggers, John; Nathan, Nicole; Conte, Kathleen; Wolfenden, Luke

2017-12-01

Children attending centre based childcare services consume as much as two thirds of their daily dietary requirements while in care. However, such services often fail to provide foods that are consistent with guideline recommendations. Developing strategies to improve childcare service adherence to menu dietary guidelines requires a comprehensive understanding of factors that may impede or promote implementation. The primary aim of this systematic review is to describe factors (barriers and facilitators) that may influence the implementation of menu dietary guidelines regarding food provision in centre-based childcare services and to map these factors to a theoretical framework. Over 7000 citations were identified from all sources. Duplicate abstracts were removed and selection criteria applied. Twelve studies (1994-2015) were included in the review. Dual data extraction was conducted and the reported factors were synthesised using the theoretical domains framework (TDF). Barriers and facilitators identified in qualitative studies were classified into 8 and 10 of the 14 TDF domains. Barriers and facilitators reported in quantitative studies covered 6 and 3 TDF domains respectively. The most common domain of which both barriers and facilitators to the implementation of menu dietary guidelines were identified was 'environmental context and resources'. This is the first study that comprehensively assesses literature to identify factors that influence the implementation of menu dietary guidelines in childcare services utilising a theoretical framework. Findings provide guidance to support researchers and policy makers design strategies to improve menu dietary guideline implementation and, as such have the potential to improve food provision in care. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

User involvement in the implementation of clinical guidelines for common mental health disorders: a review and compilation of strategies and resources.

PubMed

Moreno, Eliana M; Moriana, Juan Antonio

2016-08-09

There is now broad consensus regarding the importance of involving users in the process of implementing guidelines. Few studies, however, have addressed this issue, let alone the implementation of guidelines for common mental health disorders. The aim of this study is to compile and describe implementation strategies and resources related to common clinical mental health disorders targeted at service users. The literature was reviewed and resources for the implementation of clinical guidelines were compiled using the PRISMA model. A mixed qualitative and quantitative analysis was performed based on a series of categories developed ad hoc. A total of 263 items were included in the preliminary analysis and 64 implementation resources aimed at users were analysed in depth. A wide variety of types, sources and formats were identified, including guides (40%), websites (29%), videos and leaflets, as well as instruments for the implementation of strategies regarding information and education (64%), self-care, or users' assessment of service quality. The results reveal the need to establish clear criteria for assessing the quality of implementation materials in general and standardising systems to classify user-targeted strategies. The compilation and description of key elements of strategies and resources for users can be of interest in designing materials and specific actions for this target audience, as well as improving the implementation of clinical guidelines.

Haemorrhagia post partum; an implementation study on the evidence-based guideline of the Dutch Society of Obstetrics and Gynaecology (NVOG) and the MOET (Managing Obstetric Emergencies and Trauma-course) instructions; the Fluxim study

PubMed Central

2010-01-01

Background One of the most important causes of maternal mortality and severe morbidity worldwide is post partum haemorrhage (PPH). Factors as substandard care are frequently reported in the international literature and there are similar reports in the Netherlands. The incidence of PPH in the Dutch population is 5% containing 10.000 women a year. The introduction of an evidence-based guideline on PPH by the Dutch society of Obstetrics and Gynaecology (NVOG) and the initiation of the MOET course (Managing Obstetrics Emergencies and Trauma) did not lead to a reduction of PPH. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions. Therefore, the aim of this study is to develop and test a tailored strategy to implement both the NVOG guideline and MOET-instructions Methods/Design One step in the development procedure is to evaluate the implementation of the guideline and MOET-instructions in the current care. Therefore measurement of the actual care will be performed in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labour of 320 women with a high risk of PPH using quality indicators extracted from the NVOG guideline and MOET instructions. In the next step barriers and facilitators for guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients, followed by a questionnaire study among all Dutch gynaecologists and midwives to quantify the barriers mentioned. Based on the outcomes, a tailored strategy to implement the NVOG guideline and MOET-instructions will be developed and tested in a feasibility study in 4 hospitals, including effect-, process- and cost evaluation. Discussion This study will provide insight into current Dutch practice, in particular to what extent the PPH guidelines of the NVOG and the MOET-instructions have been implemented in the actual care, and into the barriers and facilitators regarding guideline adherence. The knowledge of the feasibility study regarding the effects and costs of the tailored strategy and the experiences of the users can be used in countries with a relatively high incidence of PPH. Trial Registration ClinicTrials.gov NCT00928863 PMID:20102607

Hospital implementation of resuscitation guidelines and review of CPR training programmes: a nationwide study.

PubMed

Schmidt, Anders S; Lauridsen, Kasper G; Adelborg, Kasper; Løfgren, Bo

2016-06-01

This study aimed to investigate cardiopulmonary resuscitation (CPR) guideline implementation and CPR training in hospitals. This nationwide study included mandatory resuscitation protocols from each Danish hospital. Protocols were systematically reviewed for adherence to the European Resuscitation Council (ERC) 2010 guidelines and CPR training in each hospital. Data were included from 45 of 47 hospitals. Adherence to the ERC basic life support (BLS) algorithm was 49%, whereas 63 and 58% of hospitals adhered to the recommended chest compression depth and rate. Adherence to the ERC advanced life support (ALS) algorithm was 81%. Hospital BLS course duration was [median (interquartile range)] 2.3 (1.5-2.5) h, whereas ALS course duration was 4.0 (2.5-8.0) h. Implementation of ERC 2010 guidelines on BLS is limited in Danish hospitals 2 years after guideline publication, whereas the majority of hospitals adhere to the ALS algorithm. CPR training differs among hospitals.

Intervention mapping for the development of a strategy to implement the insurance medicine guidelines for depression

PubMed Central

2011-01-01

Background This article describes the development of a strategy to implement the insurance medicine guidelines for depression. Use of the guidelines is intended to result in more transparent and uniform assessment of claimants with depressive symptoms. Methods The implementation strategy was developed using the Intervention Mapping (IM) method for alignment with insurance-medical practice. The ASE behavioural explanation model (Attitude, Social Influence and Self-Efficacy) was used as theoretical basis for the development work. A literature study of implementation strategies and interviews with insurance physicians were performed to develop instruments for use with the guideline. These instruments were designed to match the needs and the working circumstances of insurance physicians. Performance indicators to measure the quality of the assessment and the adherence to the guidelines were defined with input from insurance physicians. Results This study resulted in the development of a training course to teach insurance physicians how to apply the guidelines for depression, using the aforementioned instruments. The efficacy of this training course will be evaluated in a Randomized Controlled Trial. Conclusions The use of IM made it possible to develop guideline support instruments tailored to insurance medical practice. PMID:21208413

Increased analgesia administration in emergency medicine after implementation of revised guidelines.

PubMed

Van Woerden, Geesje; Van Den Brand, Crispijn L; Den Hartog, Cornelis F; Idenburg, Floris J; Grootendorst, Diana C; Van Der Linden, M Christien

2016-12-01

The most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management. We conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4-10) at the ED. A total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001). After implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).

Speech pathologists' experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study.

PubMed

Hadely, Kathleen A; Power, Emma; O'Halloran, Robyn

2014-03-06

Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists' implementation of stroke CPGs. This study aimed to describe speech pathologists' experiences and current use of guidelines, and to identify what factors influence speech pathologists' implementation of stroke CPGs. Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data. 320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline "somewhat useful" or "very useful". Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided. There are many different factors that can influence speech pathologists' implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study.

PubMed

Balbale, Salva N; Hill, Jennifer N; Guihan, Marylou; Hogan, Timothy P; Cameron, Kenzie A; Goldstein, Barry; Evans, Charlesnika T

2015-09-09

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released. Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide. The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions. Successful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.

Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review.

PubMed

Watkins, Kim; Wood, Helen; Schneider, Carl R; Clifford, Rhonda

2015-10-29

The clinical role of community pharmacists is expanding, as is the use of clinical guidelines in this setting. However, it is unclear which strategies are successful in implementing clinical guidelines and what outcomes can be achieved. The aim of this systematic review is to synthesise the literature on the implementation of clinical guidelines to community pharmacy. The objectives are to describe the implementation strategies used, describe the resulting outcomes and to assess the effectiveness of the strategies. A systematic search was performed in six electronic databases (Medline, EMBASE, CINAHL, Web of Science, Informit, Cochrane Library) for relevant articles. Studies were included if they reported on clinical guidelines implementation strategies in the community pharmacy setting. Two researchers completed the full-search strategy, data abstraction and quality assessments, independently. A third researcher acted as a moderator. Quality assessments were completed with three validated tools. A narrative synthesis was performed to analyse results. A total of 1937 articles were retrieved and the titles and abstracts were screened. Full-text screening was completed for 36 articles resulting in 19 articles (reporting on 22 studies) included for review. Implementation strategies were categorised according to a modified version of the EPOC taxonomy. Educational interventions were the most commonly utilised strategy (n = 20), and computerised decision support systems demonstrated the greatest effect (n = 4). Most studies were multifaceted and used more than one implementation strategy (n = 18). Overall outcomes were moderately positive (n = 17) but focused on process (n = 22) rather than patient (n = 3) or economic outcomes (n = 3). Most studies (n = 20) were rated as being of low methodological quality and having low or very low quality of evidence for outcomes. Studies in this review did not generally have a well thought-out rationale for the choice of implementation strategy. Most utilised educational strategies, but the greatest effect on outcomes was demonstrated using computerised clinical decision support systems. Poor methodology, in the majority of the research, provided insufficient evidence to be conclusive about the best implementation strategies or the benefit of clinical guidelines in this setting. However, the generally positive outcomes across studies and strategies indicate that implementing clinical guidelines to community pharmacy might be beneficial. Improved methodological rigour in future research is required to strengthen the evidence for this hypothesis. PROSPERO 2012: CRD42012003019 .

Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study.

PubMed

Sinuff, Tasnim; Muscedere, John; Cook, Deborah J; Dodek, Peter M; Anderson, William; Keenan, Sean P; Wood, Gordon; Tan, Richard; Haupt, Marilyn T; Miletin, Michael; Bouali, Redouane; Jiang, Xuran; Day, Andrew G; Overvelde, Janet; Heyland, Daren K

2013-01-01

Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

Bridging the gap between guidelines and practice in the management of emerging infectious diseases: a qualitative study of emergency nurses.

PubMed

Lam, Stanley Kk; Kwong, Enid Wy; Hung, Maria Sy; Pang, Samantha Mc

2016-10-01

To explore the difficulties and strategies regarding guideline implementation among emergency nurses. Emerging infectious diseases remain an underlying source of global health concern. Guidelines for accident and emergency departments would require adjustments for infectious disease management. However, disparities between guidelines and nurses' practice are frequently reported, which undermines the implementation of these guidelines into practice. This article explores the experience of frontline emergency nurses regarding guideline implementation and provides an in-depth account of their strategies in bridging guideline-practice gaps. A qualitative descriptive design was used. Semi-structured, face-to-face, individual interviews were conducted between November 2013-May 2014. A purposive sample of 12 frontline emergency nurses from five accident and emergency departments in Hong Kong were recruited. The audio-recorded interviews were transcribed verbatim and analysed with a qualitative content analysis approach. Four key categories associated with guideline-practice gaps emerged, including getting work done, adapting to accelerated infection control measures, compromising care standards and resolving competing clinical judgments across collaborating departments. The results illustrate that the guideline-practice gaps could be associated with inadequate provision of corresponding organisational supports after guidelines are established. The nurses' experiences have uncovered the difficulties in the implementation of guidelines in emergency care settings and the corresponding strategies used to address these problems. The nurses' experiences reflect their endeavour in adjusting accordingly and adapting themselves to their circumstances in the face of unfeasible guidelines. It is important to customise guidelines to the needs of frontline nurses. Maintaining cross-departmental consensus on guideline interpretation and operation is also indicated as an important component for effective guideline implementation. © 2016 John Wiley & Sons Ltd.

A mixed methods pilot study with a cluster randomized control trial to evaluate the impact of a leadership intervention on guideline implementation in home care nursing.

PubMed

Gifford, Wendy A; Davies, Barbara; Graham, Ian D; Lefebre, Nancy; Tourangeau, Ann; Woodend, Kirsten

2008-12-10

Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications) was not assessed at all. Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing. The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers. Two phase mixed methods design is proposed (ISRCTN 12345678). Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers) will evaluate differences in outcomes between two implementation strategies. Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations. In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a) printed materials, b) one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c) three post-workshop teleconferences. This study will provide vital information on which leadership strategies are well received to facilitate and support guideline implementation. The anticipated outcomes will provide information to assist with effective management of foot ulcers for people with diabetes. By tracking clinical outcomes associated with guideline implementation, health care administrators will be better informed to influence organizational and policy decision-making to support evidence-based quality care. Findings will be useful to inform the design of future multi-centered trials on various clinical topics to enhance knowledge translation for positive outcomes.

[Implementation of the German S3 guidelines on dementia in clinical practice: wish or reality?

PubMed

Lohmann, H; Kulessa, F; Holling, H; Johnen, A; Reul, S; Lueg, G; Duning, T

2017-08-01

Published in 2009, the German S3 guidelines on dementia define a milestone in quality improvement of the diagnostics and treatment of dementia. In clinical practice patients suffering from dementia are primarily treated by physicians in private practice; therefore, this study examined how the guidelines are implemented in outpatient clinical settings. Furthermore, it aimed at the identification of behavioral determinants that govern the actual diagnostic and therapeutic approach in clinical practice. Physicians involved in the primary care of dementia patients were asked to participate in a nationwide internet survey. The questionnaire covered aspects on the diagnostic and therapeutic care of dementia patients as recommended by the S3 guidelines. Behavioral determinants of the implementation of the guidelines (e. g. treatment decisions) were derived from an established psychological prediction model. Out of a total of 2755 physicians contacted, the data of 225 participants could be used in this study. The diagnostic recommendations of the S3 guidelines were implemented in satisfactory measures (e.g. combined cognitive screening in at least 68%, cerebral neuroimaging in at least 93% and specific laboratory diagnostics in at least 27% of cases); however, only two thirds of the patients with indications for a guideline-conform therapy were treated in accordance with the S3 guidelines. There was a substantial prescription of non-recommended drugs and a notable long-term use of antipsychotic drugs (prescription by at least 14% of non-neurological medical specialists and by 8% of neurologists and psychiatrists). When considering the behavioral determinants in the implementation of the guidelines, normative assumptions ("my colleagues and patients expect me to comply with the guidelines") surprisingly had the highest impact, which was then followed by attitudes towards the behavior ("utilization of the guidelines improves diagnostics and therapy"). The German S3 guidelines on dementia were satisfactorily implemented in outpatient clinical practice; however, deficits existed in the frequency of the pharmaceutical treatment of patients with indications for therapy, the prescription of non-recommended drugs and the relatively common use of permanent neuroleptic medications. Interestingly, the motivation for implementation of the guidelines was not primarily influenced by the physicians' personal convictions but mainly stimulated by the expectations of others.

From Delivery to Adoption of Physical Activity Guidelines: Realist Synthesis

PubMed Central

2017-01-01

Background: Evidence-based guidelines published by health authorities for the promotion of health-enhancing physical activity (PA), continue to be implemented unsuccessfully and demonstrate a gap between evidence and policies. This review synthesizes evidence on factors influencing delivery, adoption and implementation of PA promotion guidelines within different policy sectors (e.g., health, transport, urban planning, sport, education). Methods: Published literature was initially searched using PubMed, EBSCO, Google Scholar and continued through an iterative snowball technique. The literature review spanned the period 2002–2017. The realist synthesis approach was adopted to review the content of 39 included studies. An initial programme theory with a four-step chain from evidence emersion to implementation of guidelines was tested. Results: The synthesis furthers our understanding of the link between PA guidelines delivery and the actions of professionals responsible for implementation within health services, school departments and municipalities. The main mechanisms identified for guidance implementation were scientific legitimation, enforcement, feasibility, familiarity with concepts and PA habits. Threats emerged to the successful implementation of PA guidelines at national/local jurisdictional levels. Conclusions: The way PA guidelines are developed may influence their adoption by policy-makers and professionals. Useful lessons emerged that may inform synergies between policymaking and professional practices, promoting win-win multisectoral strategies. PMID:28991184

The European Society of Human Reproduction and Embryology guideline for the diagnosis and treatment of endometriosis: an electronic guideline implementability appraisal

PubMed Central

2011-01-01

Background Clinical guidelines are intended to improve healthcare. However, even if guidelines are excellent, their implementation is not assured. In subfertility care, the European Society of Human Reproduction and Embryology (ESHRE) guidelines have been inventoried, and their methodological quality has been assessed. To improve the impact of the ESHRE guidelines and to improve European subfertility care, it is important to optimise the implementability of guidelines. We therefore investigated the implementation barriers of the ESHRE guideline with the best methodological quality and evaluated the used instrument for usability and feasibility. Methods We reviewed the ESHRE guideline for the diagnosis and treatment of endometriosis to assess its implementability. We used an electronic version of the guideline implementability appraisal (eGLIA) instrument. This eGLIA tool consists of 31 questions grouped into 10 dimensions. Seven items address the guideline as a whole, and 24 items assess the individual recommendations in the guideline. The eGLIA instrument identifies factors that influence the implementability of the guideline recommendations. These factors can be divided into facilitators that promote implementation and barriers that oppose implementation. A panel of 10 experts from three European countries appraised all 36 recommendations of the guideline. They discussed discrepancies in a teleconference and completed a questionnaire to evaluate the ease of use and overall utility of the eGLIA instrument. Results Two of the 36 guideline recommendations were straightforward to implement. Five recommendations were considered simply statements because they contained no actions. The remaining 29 recommendations were implementable with some adjustments. We found facilitators of the guideline implementability in the quality of decidability, presentation and formatting, apparent validity, and novelty or innovation of the recommendations. Vaguely defined actions, lack of facilities, immeasurable outcomes, and inflexibility within the recommendations formed barriers to implementation. The eGLIA instrument was generally useful and easy to use. However, assessment with the eGLIA instrument is very time-consuming. Conclusions The ESHRE guideline for the diagnosis and treatment of endometriosis could be improved to facilitate its implementation in daily practice. The eGLIA instrument is a helpful tool for identifying obstacles to implementation of a guideline. However, we recommend a concise version of this instrument. PMID:21247418

Feasibility and efficacy of sepsis management guidelines in a pediatric intensive care unit in Saudi Arabia: a quality improvement initiative.

PubMed

Hasan, Gamal M; Al-Eyadhy, Ayman A; Temsah, Mohamed-Hani A; Al-Haboob, Ali A; Alkhateeb, Mohammad A; Al-Sohime, Fahad

2018-04-25

Evaluation of feasibility and effectiveness of Surviving Sepsis Campaign (SSC) Guidelines implementation at a Pediatric Intensive Care Unit (PICU) in Saudi Arabia to reduce severe sepsis associated mortality. Retrospective data analysis for a prospective quality improvement (QI) initiative. PICU at King Saud University Medical City, Saudi Arabia. Children ≤14 years of age admitted to the PICU from July 2010 to March 2011 with suspected or proven sepsis. Comparisons were made to a previously admitted group of patients with sepsis from October 2009 to June 2010. Adaptation and implementation of the Surviving Sepsis Campaign-Clinical Practice Guidelines (SSC-CPGs) through AGREE instrument and ADAPTE process. We reported pre- and post-implementation outcome of interest for this QI initiative, annual sepsis-related mortality rate. Furthermore, we reported follow-up of annual mortality rate until December 2016. Sixty-five patients was included in the study (42 in post-guidelines implementation group and 23 in pre-guidelines implementation group). Mortality was insignificantly lower in the post-implementation group (26.2% vs. 47.8%; P = 0.079). However, when adjusted for severity, identified by number of failing organs in the multivariate regression analysis, the mortality difference was favorable for the post-implementation group (P = 0.006). The lower sepsis-related mortality rate was also sustained, with an average mortality rate of 15.11% for the subsequent years (2012-16). Adaptation and implementation of SSC Guidelines in our setting support its feasibility and potential benefits. However, a larger study is recommended to explore detailed compliance rates.

Representing nursing guideline with unified modeling language to facilitate development of a computer system: a case study.

PubMed

Choi, Jeeyae; Choi, Jeungok E

2014-01-01

To provide best recommendations at the point of care, guidelines have been implemented in computer systems. As a prerequisite, guidelines are translated into a computer-interpretable guideline format. Since there are no specific tools to translate nursing guidelines, only a few nursing guidelines are translated and implemented in computer systems. Unified modeling language (UML) is a software writing language and is known to well and accurately represent end-users' perspective, due to the expressive characteristics of the UML. In order to facilitate the development of computer systems for nurses' use, the UML was used to translate a paper-based nursing guideline, and its ease of use and the usefulness were tested through a case study of a genetic counseling guideline. The UML was found to be a useful tool to nurse informaticians and a sufficient tool to model a guideline in a computer program.

An Implementation Strategy to Improve the Guideline Adherence of Insurance Physicians: A Process Evaluation Alongside an Experiment in a Controlled Setting

ERIC Educational Resources Information Center

Zwerver, Feico; Bonefaas-Groenewoud, Karin; Schellart, Antonius J. M.; Anema, Johannes R.; van der Beek, Allard J.

2013-01-01

Background: We developed an implementation strategy for the insurance medicine guidelines for depression, which we implemented via a post-graduate course for insurance physicians (IPs). In this study we evaluate the physicians' experiences of the implementation strategy by measuring the following aspects: recruitment and reach, dose delivered and…

Implementation of a CT Scan Practice Guideline for Pediatric Trauma Patients Reduces Unnecessary Scans Without Impacting Outcomes.

PubMed

McGrew, Patrick R; Chestovich, Paul J; Fisher, Jay D; Kuhls, Deborah A; Fraser, Douglas R; Patel, Purvi P; Katona, Chad W; Saquib, Syed; Fildes, John J

2018-05-04

Computed Tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the utility of CT scan guidelines in the management of pediatric trauma. This study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT utilization before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis utilizing published criteria from the Pediatric Emergency Care and Research Network (PECARN). There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age<15) trauma patients seen in our TC from 2010-2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay (LOS), readmissions, and mortality. Categorical and continuous variables were analyzed with Chi-square and Wilcoxon rank-sum tests, respectively. P<0.05 was considered significant. We identified 1934 patients: 1106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8% respectively (p<0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT utilization, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Level IV, Therapeutic Study.

Connecting Marketing and Implementation Research and Library Program Development: A Case Study of the Implementation of [U.S.] National Guidelines and Standards.

ERIC Educational Resources Information Center

Haycock, Ken; Cavill, Pat

This case study examined: (1) what market research is required for planning for the implementation of "Information Power: Building Partnerships for Learning," the 1998 national guidelines for effective school library media programs; (2) what issues need to be addressed and what target audiences are required to effect change, as well as…

Determinants of implementation of maternal health guidelines in Kosovo: mixed methods study

PubMed Central

2013-01-01

Background One of the challenges to implementing clinical practice guidelines is the need to adapt guidelines to the local context and identify barriers to their uptake. Several models of framework are available to consider for use in guideline adaptation. Methods We completed a multiphase study to explore the implementation of maternal health guidelines in Kosovo, focusing on determinants of uptake and methods to contextualize for local use. The study involved a survey, individual interviews, focus groups, and a consensus meeting with relevant stakeholders, including clinicians (obstetricians, midwives), managers, researchers, and policy makers from the national Ministry of Health and the World Health Organization office in Pristina, Kosovo. Results Participants identified several important barriers to implementation. First, lack of communication between clinicians and ministry representatives was seen as leading to duplication of effort in creating or adapting guidelines, as well as substantial mistrust between clinicians and policy makers. Second, there was a lack of communication across clinical groups that provide obstetric care and a lack of integration across the entire healthcare system, including rural and urban centers. This fragmentation was thought to have directly resulted from the war in 1998 – 1999. Third, the conflict substantially and adversely affected the healthcare infrastructure in Kosovo, which has resulted in an inability to monitor quality of care across the country. Furthermore, the impact on infrastructure has affected the ability to access required medications consistently and to smoothly transfer patients from rural to urban centers. Another issue raised during this project was the appropriateness of including guideline recommendations perceived to be ‘aspirational’. Conclusions Implementing clinical practice guidelines in low- and middle-income countries (LMICs) requires consideration of several specific barriers. Particularly pertinent to this study were the effects of recent conflict and the resulting fragmentation of healthcare and communication strategies among relevant stakeholders. However, as Kosovo rebuilds and invests in infrastructure after the conflict, there is a tremendous opportunity to create comprehensive, thoughtful strategies to monitor and improve quality of care. To avoid duplication of effort, it may be beneficial for LMICs to share information on assessing barriers as well as on guideline implementation strategies. PMID:24016149

Speech pathologists’ experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study

PubMed Central

2014-01-01

Background Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists’ implementation of stroke CPGs. This study aimed to describe speech pathologists’ experiences and current use of guidelines, and to identify what factors influence speech pathologists’ implementation of stroke CPGs. Methods Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data. Results 320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline “somewhat useful” or “very useful”. Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided. Conclusions There are many different factors that can influence speech pathologists’ implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies. PMID:24602148

Implementation of study results in guidelines and adherence to guidelines in clinical practice.

PubMed

Waldfahrer, Frank

2016-01-01

Guidelines were introduced in hospital- and practice-based otorhinolaryngology in the 1990ies, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head & Neck Surgery. The society has cooperated in further 34 guidelines. The quality of the guidelines has been continuously improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF). Since increasing digitalization has made access to scientific publications quicker and simpler, relevant study results can be incorporated in guidelines more easily today than in the analog world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines.

Implementation of study results in guidelines and adherence to guidelines in clinical practice

PubMed Central

Waldfahrer, Frank

2016-01-01

Guidelines were introduced in hospital- and practice-based otorhinolaryngology in the 1990ies, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head & Neck Surgery. The society has cooperated in further 34 guidelines. The quality of the guidelines has been continuously improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF). Since increasing digitalization has made access to scientific publications quicker and simpler, relevant study results can be incorporated in guidelines more easily today than in the analog world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines. PMID:28025601

Towards local implementation of Dutch health policy guidelines: a concept-mapping approach.

PubMed

Kuunders, Theo J M; van Bon-Martens, Marja J H; van de Goor, Ien A M; Paulussen, Theo G W M; van Oers, Hans A M

2017-02-22

To develop a targeted implementation strategy for a municipal health policy guideline, implementation targets of two guideline users [Regional Health Services (RHSs)] and guideline developers of leading national health institutes were made explicit. Therefore, characteristics of successful implementation of the guideline were identified. Differences and similarities in perceptions of these characteristics between RHSs and developers were explored. Separate concept mapping procedures were executed in two RHSs, one with representatives from partner local health organizations and municipalities, the second with RHS members only. A third map was conducted with the developers of the guideline. All mapping procedures followed the same design of generating statements up to interpretation of results with participants. Concept mapping, as a practical implementation tool, will be discussed in the context of international research literature on guideline implementation in public health. Guideline developers consider implementation successful when substantive components (health issues) of the guidelines, content are visible in local policy practice. RHSs, local organizations and municipalities view the implementation process itself within and between organizations as more relevant, and state that usability of the guideline for municipal policy and commitment by officials and municipal managers are critical targets for successful implementation. Between the RHSs, differences in implementation targets were smaller than between RHSs and guideline developers. For successful implementation, RHSs tend to focus on process targets while developers focus more on the thematic contents of the guideline. Implications of these different orientations for implementation strategies are dealt with in the discussion. © The Author 2017. Published by Oxford University Press.

From policy to practice: implementation of physical activity and food policies in schools

PubMed Central

2013-01-01

Purpose Public policies targeting the school setting are increasingly being used to address childhood obesity; however, their effectiveness depends on their implementation. This study explores the factors which impeded or facilitated the implementation of publicly mandated school-based physical activity and nutrition guidelines in the province of British Columbia (BC), Canada. Methods Semi-structured interviews were conducted with 50 school informants (17 principals - 33 teacher/school informants) to examine the factors associated with the implementation of the mandated Daily Physical Activity (DPA) and Food and Beverage Sales in Schools (FBSS) guidelines. Coding used a constructivist grounded theory approach. The first five transcripts and every fifth transcript thereafter were coded by two independent coders with discrepancies reconciled by a third coder. Data was coded and analysed in the NVivo 9 software. Concept maps were developed and current theoretical perspectives were integrated in the later stages of analysis. Results The Diffusion of Innovations Model provided an organizing framework to present emergent themes. With the exception of triability (not relevant in the context of mandated guidelines/policies), the key attributes of the Diffusion of Innovations Model (relative advantage, compatibility, complexity, and observability) provided a robust framework for understanding themes associated with implementation of mandated guidelines. Specifically, implementation of the DPA and FBSS guidelines was facilitated by perceptions that they: were relatively advantageous compared to status quo; were compatible with school mandates and teaching philosophies; had observable positive impacts and impeded when perceived as complex to understand and implement. In addition, a number of contextual factors including availability of resources facilitated implementation. Conclusions The enactment of mandated policies/guidelines for schools is considered an essential step in improving physical activity and healthy eating. However, policy makers need to: monitor whether schools are able to implement the guidelines, support schools struggling with implementation, and document the impact of the guidelines on students’ behaviors. To facilitate the implementation of mandated guidelines/policies, the Diffusion of Innovations Model provides an organizational framework for planning interventions. Changing the school environment is a process which cannot be undertaken solely by passive means as we know that such approaches have not resulted in adequate implementation. PMID:23731803

From policy to practice: implementation of physical activity and food policies in schools.

PubMed

Mâsse, Louise C; Naiman, Daniel; Naylor, Patti-Jean

2013-06-03

Public policies targeting the school setting are increasingly being used to address childhood obesity; however, their effectiveness depends on their implementation. This study explores the factors which impeded or facilitated the implementation of publicly mandated school-based physical activity and nutrition guidelines in the province of British Columbia (BC), Canada. Semi-structured interviews were conducted with 50 school informants (17 principals - 33 teacher/school informants) to examine the factors associated with the implementation of the mandated Daily Physical Activity (DPA) and Food and Beverage Sales in Schools (FBSS) guidelines. Coding used a constructivist grounded theory approach. The first five transcripts and every fifth transcript thereafter were coded by two independent coders with discrepancies reconciled by a third coder. Data was coded and analysed in the NVivo 9 software. Concept maps were developed and current theoretical perspectives were integrated in the later stages of analysis. The Diffusion of Innovations Model provided an organizing framework to present emergent themes. With the exception of triability (not relevant in the context of mandated guidelines/policies), the key attributes of the Diffusion of Innovations Model (relative advantage, compatibility, complexity, and observability) provided a robust framework for understanding themes associated with implementation of mandated guidelines. Specifically, implementation of the DPA and FBSS guidelines was facilitated by perceptions that they: were relatively advantageous compared to status quo; were compatible with school mandates and teaching philosophies; had observable positive impacts and impeded when perceived as complex to understand and implement. In addition, a number of contextual factors including availability of resources facilitated implementation. The enactment of mandated policies/guidelines for schools is considered an essential step in improving physical activity and healthy eating. However, policy makers need to: monitor whether schools are able to implement the guidelines, support schools struggling with implementation, and document the impact of the guidelines on students' behaviors. To facilitate the implementation of mandated guidelines/policies, the Diffusion of Innovations Model provides an organizational framework for planning interventions. Changing the school environment is a process which cannot be undertaken solely by passive means as we know that such approaches have not resulted in adequate implementation.

Implementation of Guidelines for Effective Fieldwork Designs: Exploring Learning Activities, Learning Processes, and Student Engagement in the Classroom and the Field

ERIC Educational Resources Information Center

Remmen, Kari Beate; Frøyland, Merethe

2014-01-01

Teachers find the implementation of fieldwork challenging. Therefore, this study investigates two teachers' implementation of theoretical guidelines for student-centered fieldwork activities, following their participation in a professional development course focusing on earth science fieldwork pedagogy. Video observation and instructional…

Suicide Prevention Guideline Implementation in Specialist Mental Healthcare Institutions in The Netherlands.

PubMed

Mokkenstorm, Jan; Franx, Gerdien; Gilissen, Renske; Kerkhof, Ad; Smit, Johannes Hendrikus

2018-05-03

In The Netherlands, on average 40% of all suicides concern patients treated by mental healthcare institutions (MHIs). Recent evidence indicates that implemented guideline recommendations significantly reduce the odds for patients to die by suicide. Implementation of the multidisciplinary guideline for diagnosis and treatment of suicidal behaviors is a main objective of the Dutch National Suicide Prevention Strategy. To this end, 24 MHIs that collectively reported 73% of patient suicides in 2015 received an educational outreach intervention offered by the national center of expertise. To investigate changes in levels of implementation of guideline recommendations; and to assess the degree of variation on suicide prevention policies and practices between MHIs. Implementation study with a prospective cohort design studying change over time on all domains of a Suicide Prevention Monitor, a guideline-based instrument assessing suicide prevention policies and practices within MHIs. Data were collected in six-month intervals between 2015 and 2017. MHIs improved significantly on four out of ten domains: the development of an organizational suicide prevention policy; monitoring and trend-analysis of suicides numbers; evaluations after suicide; and clinician training. No improvement was measured on the domains pertaining to multi-annual training policies; collaborative care with external partners; recording and evaluation of suicide attempts; routine assessment of suicidality in all patients; safety planning and involving next of kin and carers. Furthermore, marked practice variation between MHIs was found which did not decrease over time. This study shows significant improvement in the implementation of four out of ten guideline-based suicide prevention policies in 24 specialist mental healthcare institutions in The Netherlands. The implementation level of suicide prevention policies and practices still appears to vary significantly between MHIs in The Netherlands.

Suicide Prevention Guideline Implementation in Specialist Mental Healthcare Institutions in The Netherlands

PubMed Central

Franx, Gerdien; Gilissen, Renske; Kerkhof, Ad; Smit, Johannes Hendrikus

2018-01-01

In The Netherlands, on average 40% of all suicides concern patients treated by mental healthcare institutions (MHIs). Recent evidence indicates that implemented guideline recommendations significantly reduce the odds for patients to die by suicide. Implementation of the multidisciplinary guideline for diagnosis and treatment of suicidal behaviors is a main objective of the Dutch National Suicide Prevention Strategy. To this end, 24 MHIs that collectively reported 73% of patient suicides in 2015 received an educational outreach intervention offered by the national center of expertise. Aim: To investigate changes in levels of implementation of guideline recommendations; and to assess the degree of variation on suicide prevention policies and practices between MHIs. Methods: Implementation study with a prospective cohort design studying change over time on all domains of a Suicide Prevention Monitor, a guideline-based instrument assessing suicide prevention policies and practices within MHIs. Data were collected in six-month intervals between 2015 and 2017. Results: MHIs improved significantly on four out of ten domains: the development of an organizational suicide prevention policy; monitoring and trend-analysis of suicides numbers; evaluations after suicide; and clinician training. No improvement was measured on the domains pertaining to multi-annual training policies; collaborative care with external partners; recording and evaluation of suicide attempts; routine assessment of suicidality in all patients; safety planning and involving next of kin and carers. Furthermore, marked practice variation between MHIs was found which did not decrease over time. Conclusion: This study shows significant improvement in the implementation of four out of ten guideline-based suicide prevention policies in 24 specialist mental healthcare institutions in The Netherlands. The implementation level of suicide prevention policies and practices still appears to vary significantly between MHIs in The Netherlands. PMID:29751572

Impact on clinical practice of the implementation of guidelines for the toxicity management of targeted therapies in kidney cancer. The protect-2 study.

PubMed

Lainez, Nuria; García-Donas, Jesús; Esteban, Emilio; Puente, Javier; Sáez, M Isabel; Gallardo, Enrique; Pinto-Marín, Álvaro; Vázquez-Estévez, Sergio; León, Luis; García-Carbonero, Icíar; Suárez-Rodríguez, Cristina; Molins, Carmen; Climent-Duran, Miguel A; Lázaro-Quintela, Martín; González Del Alba, Aranzazu; Méndez-Vidal, María José; Chirivella, Isabel; Afonso, Francisco J; López-Brea, Marta; Sala-González, Nuria; Domenech, Montserrat; Basterretxea, Laura; Santander-Lobera, Carmen; Gil-Arnáiz, Irene; Fernández, Ovidio; Caballero-Díaz, Cristina; Mellado, Begoña; Marrupe, David; García-Sánchez, José; Sánchez-Escribano, Ricardo; Fernández Parra, Eva; Villa Guzmán, José C; Martínez-Ortega, Esther; Belén González, María; Morán, Marina; Suarez-Paniagua, Beatriz; Lecumberri, María J; Castellano, Daniel

2016-02-22

The impact of such recommendations after their implementation of guidelines has not usually been evaluated. Herein, we assessed the impact and compliance with the Spanish Oncology Genitourinary Group (SOGUG) Guidelines for toxicity management of targeted therapies in metastatic renal cell carcinoma (mRCC) in daily clinical practice. Data on 407 mRCC patients who initiated first-line targeted therapy during the year before and the year after publication and implementation of the SOGUG guideline program were available from 34 Spanish Hospitals. Adherence to SOGUG Guidelines was assessed in every cycle. Adverse event (AE) management was consistent with the Guidelines as a whole for 28.7% out of 966 post-implementation cycles compared with 23.1% out of 892 pre-implementation cycles (p = 0.006). Analysis of adherence by AE in non-compliant cycles showed significant changes in appropriate management of hypertension (33% pre-implementation vs. 44.5% post-implementation cycles; p < 0.0001), diarrhea (74.0% vs. 80.5%; p = 0.011) and dyslipemia (25.0% vs. 44.6%; p < 0.001). Slight but significant improvements in AE management were detected following the implementation of SOGUG recommendations. However, room for improvement in the management of AEs due to targeted agents still remains and could be the focus for further programs in this direction.

Clinical Guidelines and Implementation into Daily Dental Practice.

PubMed

Guncu, Guliz Nigar; Nemli, Secil Karakoca; Carrilho, Eunice; Yamalık, Nermin; Volodina, Elena; Melo, Paulo; Margvelashvili, Vladimer; Rossi, Alessandra

2018-01-31

The purpose of this study is to assess the extent of the familiarity, attitude and perceptions of dental professionals regarding clinical dental guidelines and their implementation into daily dental practice. For this purpose, a questionnaire which was developed by the members of the World Dental Federation, European Regional Organization Working Group - 'Relation Between Dental Practitioner and Universities', was implemented by the National Dental Associations of six European Regional Organization-zone countries (Georgian Stomatological Association - Georgia, Associazione Nazionale Dentisti Italiani - Italy, Portuguese Dental Association - Portugal, Russian Dental Association - Russia, Swiss Dental Association - Switzerland, and Turkish Dental Association - Turkey. The questionnaire was filled by a total of 910 dental professionals who are members of one of these national dental associations and who voluntarily wanted to participate to this survey. Most of the survey participants were familiar with clinical dental guidelines (68%), claimed that they implemented them into daily practice (61.7%), and generally acknowledged their benefits (81.8%). Many participants believed that clinical dental guidelines could help to improve the clinical treatment plan (50.6 %) and the accuracy of diagnosis (39.4%); which increased with age and years of practice (p < 0.05). The most frequently perceived barrier to the effective implementation of clinical dental guidelines was expressed as 'lack of awareness', while participants suggested a role for national dental associations in spreading clinical dental guidelines. A better understanding of the perceptions and attitudes of dentists towards clinical dental guidelines and the potential impact of factors affecting such perceptions and attitudes may be of particular importance for attempts aiming at overcoming the barriers for effective implementation of clinical dental guidelines into daily practice. Despite a significant familiarity and a common positive attitude, dental professionals are likely to have different perceptions towards clinical dental guidelines, especially regarding their effective implementation into daily practice, benefits and barriers.

The Adoption of Roles by Primary Care Providers during Implementation of the New Chronic Disease Guidelines in Urban Mongolia: A Qualitative Study.

PubMed

Chimeddamba, Oyun; Ayton, Darshini; Bazarragchaa, Nansalmaa; Dorjsuren, Bayarsaikhan; Peeters, Anna; Joyce, Catherine

2016-04-07

(1) BACKGROUND: In 2011, new chronic disease guidelines were introduced across Mongolia. No formal advice was provided regarding role delineation. This study aimed to analyse the roles that different primary care providers adopted, and the variations in these, in the implementation of the guidelines in urban Mongolia; (2) METHODS: Ten group interviews with nurses and ten individual interviews each with practice doctors and practice directors were conducted. Data was analysed using a thematic approach based on the identified themes relevant to role delineation; (3) RESULTS: There was some variability and flexibility in role delineation. Factors involving teamwork, task rotation and practice flexibility facilitated well the guideline implementation. However, factors including expectations and decision making, nursing shortage, and training gaps adversely influenced in the roles and responsibilities. Some role confusion and dissatisfaction was identified, often associated with a lack of training or staff turnover; (4) CONCLUSIONS: Findings suggest that adequate ongoing training is required to maximize the range of roles particular provider types, especially primary care nurses, are competent to perform. Ensuring that role delineation is specified in guidelines could remove confusion and enhance implementation of such guidelines.

Changes in insurance physicians' attitudes, self-efficacy, intention, and knowledge and skills regarding the guidelines for depression, following an implementation strategy.

PubMed

Zwerver, Feico; Schellart, Antonius J M; Anema, Johannes R; van der Beek, Allard J

2013-03-01

To improve guideline adherence by insurance physicians (IPs), an implementation strategy was developed and investigated in a randomized controlled trial. This implementation strategy involved a multifaceted training programme for a group of IPs in applying the guidelines for depression. In this study we report the impact of the implementation strategy on the physicians' attitude, intention, self-efficacy, and knowledge and skills as behavioural determinants of guideline adherence. Any links between these self-reported behavioural determinants and levels of guideline adherence were also determined. Just before and 3 months after the implementation of the multifaceted training, a questionnaire designed to measure behavioural determinants on the basis of the ASE (attitude, social norm, self-efficacy) model was completed by the intervention (n = 21) and the control group (n = 19). Items of the questionnaire were grouped to form scales of ASE determinants. Internal consistency of the scales was calculated using Cronbach's alphas. Differences between groups concerning changes in ASE determinants, and the association of these changes with improvements in guideline adherence, were analyzed using analysis of covariance. The internal consistency of the scales of ASE determinants proved to be sufficiently reliable, with Cronbach's alphas of at least 0.70. At follow-up after 3 months, the IPs given the implementation strategy showed significant improvement over the IPs in the control group for all ASE determinants investigated. Changes in knowledge and skills were only weakly associated with improvements in guideline adherence. The implementation strategy developed for insurance physicians can increase their attitude, intention, self-efficacy, and knowledge and skills when applying the guidelines for depression. These changes in behavioural determinants might indicate positive changes in IPs' behaviour towards the use of the guidelines for depression. However, only changes in knowledge and skills related to the use of the guidelines were associated with improvements in IPs' actual performance when applying the guidelines.

How are evidence and knowledge used in orthopaedic decision-making? Three comparative case studies of different approaches to implementation of clinical guidance in practice.

PubMed

Grove, Amy; Clarke, Aileen; Currie, Graeme

2018-05-31

The uptake and use of clinical guidelines is often insufficient to change clinical behaviour and reduce variation in practice. As a consequence of diverse organisational contexts, the simple provision of guidelines cannot ensure fidelity or guarantee their use when making decisions. Implementation research in surgery has focused on understanding what evidence exists for clinical practice decisions but limits understanding to the technical, educational and accessibility issues. This research aims to identify where, when and how evidence and knowledge are used in orthopaedic decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice. We used in-depth case studies to examine guideline implementation in real-life surgical practice. We conducted comparative case studies in three English National Health Service hospitals over a 12-month period. Each in-depth case study consisted of a mix of qualitative methods including interviews, observations and document analysis. Data included field notes from observations of day-to-day practice, 64 interviews with NHS surgeons and staff and the collection of 121 supplementary documents. Case studies identified 17 sources of knowledge and evidence which influenced clinical decisions in elective orthopaedic surgery. A comparative analysis across cases revealed that each hospital had distinct approaches to decision-making. Decision-making is described as occurring as a result of how 17 types of knowledge and evidence were privileged and of how they interacted and changed in context. Guideline implementation was contingent and mediated through four distinct contextual levels. Implementation could be assessed for individual surgeons, groups of surgeons or the organisation as a whole, but it could also differ between these levels. Differences in how evidence and knowledge were used contributed to variations in practice from guidelines. A range of complex and competing sources of evidence and knowledge exists which influence the working practices of healthcare professionals. The dynamic selection, combination and use of each type of knowledge and evidence influence the implementation and use of clinical guidance in practice. Clinical guidelines are a fundamental part of practice, but represent only one type of evidence influencing clinical decisions. In the orthopaedic speciality, other distinct sources of evidence and knowledge are selected and used which impact on how guidelines are implemented. New approaches to guideline implementation need to appreciate and incorporate this diverse range of knowledge and evidence which influences clinical decisions and to take account of the changing contexts in which decisions are made.

Evaluation of a disease state management guideline for urinary tract infection.

PubMed

Zmarlicka, Monika T; Cardwell, Sophia M; Crandon, Jared L; Nicolau, David P; McClure, Mitchell H; Nailor, Michael D

2016-06-01

A urinary tract infection (UTI) disease state management guideline, including risk-based antimicrobial recommendations, Foley catheter management and transitions of care, was implemented. This study evaluated the outcomes associated with implementation of the guideline. A retrospective study was conducted between 1 July 2013 and 30 September 2013 (pre-implementation) and between 1 July 2014 and 30 September 2014 (post-implementation). Symptomatic patients treated for UTI within 24 h with an identified pathogen were included. Risk-based patient groups were community-acquired UTI, healthcare-associated UTI, or extended-spectrum β-lactamase (ESBL) history in prior 12 months. Recommended antimicrobials were ceftriaxone, cefepime ± vancomycin, or doripenem ± vancomycin, respectively. Given the low post-implementation guideline adherence, pre- and post-groups were combined to evaluate potential guideline value. Length of stay (LOS) decreased when guidelines were followed [5 (IQR 4-7) days vs. 6 (IQR 4-8) days; P = 0.03] or appropriate therapy (according to in vitro susceptibilities) was given [5 (IQR 4-7) days vs. 6 (IQR 4-9) days; P = 0.03]. Those receiving guideline-recommended antimicrobials were more likely to have appropriate therapy within 24 h (84.4% vs. 64.2%; P <0.001). On multivariate analysis, intensive care unit (ICU) admission and admission from home were associated with longer and shorter LOS, respectively. Despite less than anticipated adherence, these data suggest that the established disease state management guideline can improve outcomes in patients admitted with UTI. Copyright © 2016 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.

Tuberculosis infection control measures in health care facilities offering tb services in Ikeja local government area, Lagos, South West, Nigeria.

PubMed

Kuyinu, Y A; Mohammed, A S; Adeyeye, O O; Odugbemi, B A; Goodman, O O; Odusanya, O O

2016-03-15

Tuberculosis infection among health care workers is capable of worsening the existing health human resource problems of low--and middle-income countries. Tuberculosis infection control is often weakly implemented in these parts of the world therefore, understanding the reasons for poor implementation of tuberculosis infection control guidelines are important. This study was aimed at assessing tuberculosis infection control practices and barriers to its implementation in Ikeja, Nigeria. A cross-sectional study in 20 tuberculosis care facilities (16 public and 4 private) in Ikeja, Lagos was conducted. The study included a facility survey to assess the availability of tuberculosis infection control guidelines, the adequacy of facilities to prevent transmission of tuberculosis and observations of practices to assess the implementation of tuberculosis infection control guidelines. Four focus group discussions were carried out to highlight HCWs' perceptions on tuberculosis infection control guidelines and barriers to its implementation. The observational study showed that none of the clinics had a tuberculosis infection control plan. No clinic was consistently screening patients for cough. Twelve facilities (60%) consistently provided masks to patients who were coughing. Ventilation in the waiting areas was assessed to be adequate in 60% of the clinics while four clinics (20%) possessed N-95 respirators. Findings from the focus group discussions showed weak managerial support, poor funding, under-staffing, lack of space and not wanting to be seen as stigmatizing against tuberculosis patients as barriers that hindered the implementation of TB infection control measures. Tuberculosis infection control measures were not adequately implemented in health facilities in Ikeja, Nigeria. A multi-pronged approach is required to address the identified barriers to the implementation of tuberculosis infection control guidelines.

Survey of Implementation of Antiemetic Prescription Standards in Indian Oncology Practices and Its Adherence to the American Society of Clinical Oncology Antiemetic Clinical Guideline

PubMed Central

Patil, Vijay; Noronha, Vanita; Joshi, Amit; Parikh, Purvish; Bhattacharjee, Atanu; Chakraborty, Santam; Jandyal, Sunny; Muddu, Vamshi; Ramaswamy, Anant; Babu, K. Govinda; Lokeshwar, Nilesh; Hingmire, Sachin; Ghadyalpatil, Nikhil; Banavali, Shripad

2017-01-01

Purpose Adherence to international antiemetic prophylaxis guidelines like those of ASCO can result in better control of chemotherapy-induced nausea and vomiting; however, the extent of implementation of such guidelines in India is unknown. Therefore, this survey was planned. Methods This study was an anonymized cross-sectional survey approved by the ethics committee. Survey items were generated from the clinical questions given in the ASCO guidelines. The survey was disseminated through personal contacts at an oncology conference and via e-mail to various community oncology centers across India. The B1, B2, and B3 domains included questions regarding the optimal antiemetic prophylaxis for high, moderate, and low-minimal emetogenic regimens. Results Sixty-six (62.9%) of 105 responded and 65 centers (98.5%) were aware of the published guidelines. The partial, full, and no implementation scores were 92.5%, 4.5%, and 3.0%, respectively. Full implementation was better for the low-minimal emetogenic regimens (34.8%) than the highly emetogenic regimens (6.1%). The three most frequent reasons for hampered implementation of ASCO guidelines in routine chemotherapy practice cited by centers were a lack of sensitization (26 centers; 39.4%), lack of national guidelines (12 centers; 18.2%), and lack of administrative support (10 centers; 15.2%). Conclusion Awareness regarding ASCO antiemetic guidelines is satisfactory in Indian oncology practices; however, there is a need for sensitization of oncologists toward complete implementation of these guidelines in their clinical practice. PMID:28831443

Barriers encountered during the implementation of a policy guideline on the vaccination of health care workers during the 2013-2014 measles outbreak in the Netherlands: a qualitative study.

PubMed

Borggreve, Stephanie Jessica; Timen, Aura

2015-12-14

In 2013 the Netherlands faced a measles epidemic, during which more than 2600 individuals were infected, including 19 health care workers (HCW). Vaccinating health care workers can lead to benefits on both the individual and public health level, underscoring the need for HCW vaccination. In June of 2013 the Dutch National Institute for Public Health and the Environment (RIVM) developed a measles guideline (MG) that advised Dutch hospitals to strengthen their policies concerning measles vaccination of HCWs. A key problem with guidelines, however, is adherence, which can be due to several barriers. The objective of this research was to identify the barriers that Dutch hospital professionals encountered during the implementation of this policy guideline, in order to improve the implementation of similar policies in the future. In-depth interviews (n = 9) were conducted with 12 hospital health care professionals involved with prevention and control of communicable diseases. These participants represented ten different Dutch hospitals located in eight of the twelve different provinces. Participants were asked about their experiences during the 2013-2014 measles epidemic regarding infection prevention measures, including vaccination of HCWs, with a specific focus on barriers to the implementation of the RIVM guideline. The implementation of the MG was impeded by several (types of) barriers. First, barriers were found related to knowledge and attitude, and included lack of agreement, barriers associated with leadership and issues related to evidence-based decision making. Second, barriers related to characteristics of the guideline, mostly related to unclear or missing guideline content. Finally, contextual and social factors such as human and financial resources, belief systems, physical facilities and technical support, and national views on vaccination policies also play an important role in policy implementation. This study has provided valuable insights into the barriers infection prevention specialists encounter during the implementation of new policies concerning vaccination of HCWs in times of a major outbreak. Moreover, this study exposed the complexity and breadth of barriers that are of importance when implementing vaccination policies in the hospital setting. In order to improve the implementation of similar policies in the future, guideline developers and health care providers and administrators alike should aim to eliminate or minimise these identified barriers by taking into account the suggestions made by the authors.

Implementing nutrition guidelines for older people in residential care homes: a qualitative study using Normalization Process Theory.

PubMed

Bamford, Claire; Heaven, Ben; May, Carl; Moynihan, Paula

2012-10-30

Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. However, there is evidence that the nutritional intake of older people living in care homes is suboptimal, with high levels of saturated fat, salt, and added sugars. The UK Food Standards Agency therefore developed nutrient- and food-based guidance for residential care homes. The acceptability of these guidelines and their feasibility in practice is unknown. This study used the Normalization Process Theory (NPT) to understand the barriers and facilitators to implementing the guidelines and inform future implementation. We conducted a process evaluation in five care homes in the north of England using qualitative methods (observation and interviews) to explore the views of managers, care staff, catering staff, and domestic staff. Data were analyzed thematically and discussed in data workshops; emerging themes were then mapped to the constructs of NPT. Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people. In terms of NPT, the guidelines simply did not make sense (coherence), and as a result, relatively few staff invested in the guidelines (cognitive participation). Even where staff supported the guidelines, implementation was hampered by a lack of nutritional knowledge and institutional support (collective action). Finally, the absence of observable benefits to clients confirmed the negative preconceptions of many staff, with limited evidence of reappraisal following implementation (reflexive monitoring). The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed. Specialist support is needed to equip staff with the technical knowledge and skills required for menu analysis and development and to devise ways of evaluating the outcomes of modified menus. NPT proved useful in conceptualizing barriers to implementation; robust links with behavior-change theories would further increase the practical utility of NPT.

Implementing nutrition guidelines for older people in residential care homes: a qualitative study using Normalization Process Theory

PubMed Central

2012-01-01

Background Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. However, there is evidence that the nutritional intake of older people living in care homes is suboptimal, with high levels of saturated fat, salt, and added sugars. The UK Food Standards Agency therefore developed nutrient- and food-based guidance for residential care homes. The acceptability of these guidelines and their feasibility in practice is unknown. This study used the Normalization Process Theory (NPT) to understand the barriers and facilitators to implementing the guidelines and inform future implementation. Methods We conducted a process evaluation in five care homes in the north of England using qualitative methods (observation and interviews) to explore the views of managers, care staff, catering staff, and domestic staff. Data were analyzed thematically and discussed in data workshops; emerging themes were then mapped to the constructs of NPT. Results Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people. In terms of NPT, the guidelines simply did not make sense (coherence), and as a result, relatively few staff invested in the guidelines (cognitive participation). Even where staff supported the guidelines, implementation was hampered by a lack of nutritional knowledge and institutional support (collective action). Finally, the absence of observable benefits to clients confirmed the negative preconceptions of many staff, with limited evidence of reappraisal following implementation (reflexive monitoring). Conclusions The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed. Specialist support is needed to equip staff with the technical knowledge and skills required for menu analysis and development and to devise ways of evaluating the outcomes of modified menus. NPT proved useful in conceptualizing barriers to implementation; robust links with behavior-change theories would further increase the practical utility of NPT. PMID:23110857

The use of benzodiazepine monotherapy for major depression before and after implementation of guidelines for benzodiazepine use.

PubMed

Lai, I-C; Wang, M-T; Wu, B-J; Wu, H-H; Lian, P-W

2011-10-01

The Department of Health (DOH) in Taiwan issued the 'Guidelines for Benzodiazepine Use in Sedation and Hypnosis' in March 2004, which clearly stated that benzodiazepines (BZDs) should not be used alone for the treatment of depression. However, the extent to which clinicians comply with the BZD guidelines was not known. This study aimed to evaluate whether sole prescribing of BZDs for major depression decreased after the implementation of the BZD guidelines. This was a retrospective longitudinal trend analysis by analyzing the Longitudinal Health Insurance Database (LHID) from September 2002 to September 2005. The LHID contains all claims data from a random sample of 1,000,000 beneficiaries of the universal National Health Insurance programme in Taiwan. The 3-year study period was divided equally into six periods, before and after the implementation of the guidelines respectively. For each period, the proportion of patients with major depression (ICD-9-CM code 296.2x, 296.3x) treated with BZDs without any concomitant antidepressant was calculated in order to conduct a trend analysis. A total of 5463 prescriptions of BZDs solely used for major depression were observed in the entire study period. In more than 80% of the BZD prescriptions in which BZDs were used alone for major depression, they were prescribed at doses higher than one prescribed daily dose/defined daily dose and were supplied for more than 7 days. The number of outpatients with major depression ranged from 2137 to 3326 during the 12 periods. The proportion of depressed patients treated with BZDs alone per 3 months (i.e., the non-compliance rate) fluctuated from 6·7% to 9·4% before implementation of the guidelines, and from 8·0% to 9·4% after implementation, in outpatient settings. In addition, the guideline non-adherence rates in inpatient settings varied from 7·0% to 11·8% and from 7·8% to 12·6% before and after the implementation of the BZD guidelines respectively. Further trend analyses indicated that the implementation of the guidelines was not associated with a reduced rate of sole prescribing of BZDs for major depression in either inpatient (P = 0·083) or outpatient settings (P = 0·925). The formulation and implementation of the BZD guidelines appear not to be associated with a reduced rate of sole prescribing of BZDs for major depression, and more comprehensive efforts are required. © 2010 The Authors. JCPT © 2010 Blackwell Publishing Ltd.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

PubMed

Longman, Jo M; Adams, Catherine M; Johnston, Jennifer J; Passey, Megan E

2018-03-01

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up. semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines. antenatal care in the NSW public health system. 27 maternity service managers, obstetricians and midwives. participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour. these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines. Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence. Copyright © 2018 Elsevier Ltd. All rights reserved.

Implementation of National Guidelines for Healthy School Meals: The Relationship between Process and Outcome

ERIC Educational Resources Information Center

Holthe, Asle; Larsen, Torill; Samdal, Oddrun

2011-01-01

The implementation of policy interventions at the school level is often considered an organizational change process. The main goal of the present study was to examine the degree of implementation of Norwegian national guidelines for healthy school meals and how organizational capacity at the school level contributed to the degree of…

Opening the black box: a study of the process of NICE guidelines implementation.

PubMed

Spyridonidis, Dimitrios; Calnan, Michael

2011-10-01

This study informs 'evidence-based' implementation by using an innovative methodology to provide further understanding of the implementation process in the English NHS using two distinctly different NICE clinical guidelines as exemplars. The implementation process was tracked retrospectively and prospectively using a comparative case-study and longitudinal design. 74 unstructured interviews were carried out with 48 key informants (managers and clinicians) between 2007 and 2009. This study has shown that the NICE guidelines implementation process has both planned and emergent components, which was well illustrated by the use of the prospective longitudinal design in this study. The implementation process might be characterised as strategic and planned to begin with but became uncontrolled and subject to negotiation as it moved from the planning phase to adoption in everyday practice. The variations in the implementation process could be best accounted for in terms of differences in the structure and nature of the local organisational context. The latter pointed to the importance of managers as well as clinicians in decision-making about implementation. While national priorities determine the context for implementation the shape of the process is influenced by the interactions between doctors and managers, which influence the way they respond to external policy initiatives such as NICE guidelines. NICE and other national health policy-makers need to recognise that the introduction of planned change 'initiatives' in clinical practice are subject to social and political influences at the micro level as well as the macro level. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Effects of an electronic reminder system on guideline-concordant treatment of psychotic disorders : Results from a pilot feasibility trial.

PubMed

Franke, Irina; Thier, Sarah; Riecher-Rössler, Anita

2016-12-01

Adherence to evidence-based guidelines is essential for the treatment outcome of psychotic disorders. Previous studies showed that IT-supported pathways are able to increase guideline adherence in psychiatric care. This paper describes a pilot study on the development of an electronic recall-reminder-system (RRS) for supporting guideline-adherent treatment in outpatient care of patients with chronic psychotic disorders and analyses its feasibility. Guidelines were integrated in the RRS software M.E.M.O.R.E.S. Software training for the staff was provided. We compared the number of conducted vs. guideline-recommended interventions 6 months before and after implementation. Subsequently both the caregivers' and the patients' satisfaction with the RRS was evaluated. Guideline adherence in general was low and the RRS was barely used. After its implementation a significant increase was observed in chemogram-check-ups and diagnostics regarding cardiovascular risks (esp. ECG). Both patients and professionals described problems with integrating the RRS in their daily routine and questioned the usefulness of the guidelines for chronically ill, although they basically approved its importance and usefulness. Participants appreciated the idea of supporting guideline adherence with an IT-system, but there seemed to be major obstacles to implementation: caregivers appear to be concerned of being exposed or questioned, technical difficulties might lead to avoidance, and there seems to be a lack of knowledge and awareness about the health risks for individuals with psychotic disorders. Possibly guidelines adapted for the chronically ill would find more acceptance. Technical simplifications and better information should be considered prior to further attempts to implement IT-supported guidelines in order to increase acceptance.

The influence of standards and clinical guidelines on prosthetic and orthotic service quality: a scoping review.

PubMed

Sadeghi-Demneh, Ebrahim; Forghany, Saeed; Onmanee, Pornsuree; Trinler, Ursula; Dillon, Michael P; Baker, Richard

2017-06-20

Standards and guidelines are an integral part of prosthetic and orthotic service delivery in the developed world underpinned by an assumption that they lead to improved services. Implementing them has a cost, however, and that cost needs to be justified, particularly in resource-limited environments. This scoping review thus asks the question, "What is the evidence of the impact of standards and guidelines on service delivery outcomes in prosthetics and orthotics?" A structured search of three electronic databases (Medline, Scopus and Web of Science) followed by manual searching of title, abstract and full text, yielded 29 articles. Four categories of papers were identified: Descriptions and Commentaries (17 papers), Guideline Development (7), Guideline Testing (2) and Standards implementation (3). No articles were explicitly designed to assess the impact of standards and guidelines on service delivery outcomes in prosthetics and orthotics. Studies tended to be commentaries on or descriptions of guideline development, testing or implementation of standards. The literature is not sufficiently well developed to warrant the cost and effort of a systematic review. Future primary research should seek to demonstrate whether and how guidelines and standards improve the outcomes for people that require prostheses, orthoses and other assistive devices. Implications for Rehabilitation International Standards and Clinical Guidelines are now an integral part of clinical service provision in prosthetics and orthotics in the developed world. Complying with standards and guidelines has a cost and, particularly in resource-limited environments, it should be possible to justify this in terms of the resulting benefits. This scoping review concludes that there have been no previous studies designed to directly quantify the effects of implementing standards and guidelines on service delivery.

75 FR 48934 - Coral Reef Conservation Program Implementation Guidelines

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-12

...-01] RIN 0648-ZC19 Coral Reef Conservation Program Implementation Guidelines AGENCY: National Oceanic... Guidelines (Guidelines) for the Coral Reef Conservation Program (CRCP or Program) under the Coral Reef... assistance for coral reef conservation projects under the Act. NOAA revised the Implementation Guidelines for...

Improvement in safety monitoring of biologic response modifiers after the implementation of clinical care guidelines by a specialty.

PubMed

Hanson, Rebekah L; Gannon, Michael J; Khamo, Nehrin; Sodhi, Monsheel; Orr, Alexander M; Stubbings, JoAnn

2013-01-01

Tumor necrosis factor (TNF)-alpha inhibitors and other biologic response modifiers (BRMs) are frequently used to treat a variety of inflammatory diseases. Use of these agents may increase risk of serious infections, malignancies, and other complications such as worsening symptoms of heart failure or demyelinating disease. Because of these risks, a baseline assessment and routine monitoring have been recommended, but standardized guidelines for monitoring have yet to be established. To measure the compliance with the recommended safety monitoring in the Clinical Care Guidelines for BRMs at the University of Illinois Hospitals and Health Sciences System (UI Health). The Clinical Care Guidelines for BRMs was developed by a committee of pharmacists, nurses, and physicians based on an assessment of published literature and medication labeling. The guidelines included recommendations for safety monitoring prior to BRM therapy, such as the tuberculosis (TB) test, Hepatitis B surface Antigen (HBsAg) test, liver function test (LFT), complete blood count (CBC), up-to-date vaccinations, risk assessment for cancer, pregnancy testing, monitoring for contraindications with concomitant medications, concomitant disease state risk assessment, and patient education. The guidelines were introduced to UI Health in February 2012 by a systemwide email and by in-services given by the health system's Specialty Pharmacy Service. In-services were given in the clinics known to generate large numbers of BRM orders (e.g., gastroenterology and rheumatology) and at the outpatient center for infused therapies. The purpose of the in-services was to introduce providers to the guidelines and encourage their compliance. To ensure that guideline requirements were met when BRMs were ordered, a process was established to identify BRM orders, assess the orders for compliance with 4 of the safety monitoring tests from the guidelines (TB, HBsAg, LFT, and CBC), and make interventions. When necessary, Specialty Pharmacy Services coordinated with the pharmacists and other providers in the clinic to order lab tests and ensure they were completed prior to the start of therapy. Feedback was provided during the study to proactively improve compliance with the guidelines. After completion of the study, a report containing outpatient prescription orders for BRMs (abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, and tocilizumab) from August 2011 through July 2012 was generated from the electronic medical record. Retrospective analyses of completion of safety monitoring were conducted for patients administered BRM treatment. Completion rates were compared before and after implementation of guidelines in February 2012. Completion was considered to have occurred when all 4 safety monitoring tests had been conducted -TB (unless known to be positive from a previous test), HBsAg, LFT, and CBC. Completion data from August 2011 through January 2012 were before the guidelines were implemented, and data from February 2012 through July 2012 were after the guidelines. Chi square analyses were performed on completion frequencies in the patients before and after the guidelines were implemented. Of the 320 unique patient BRM orders evaluated in this study, 195 (61%) were generated in the Rheumatology clinic, 99 (31%) in the Gastroenterology clinic, 21 (6.5%) in the Dermatology clinic, and 5 (1.5%) in the Transplant clinic. Before the guidelines were implemented, 54 ( 31%) of 173 patient orders complied with the safety monitoring by having all 4 clinical tests performed at the appropriate time points. After guideline implementation, 88 (60%) of 147 patient orders were compliant and had all 4 clinical tests conducted, which represents a statistically significant improvement in the rate of compliance (Pearson chi square = 26.43, degrees of freedom (df) = 1, P  less than  0.0001). This significant improvement in compliance rates after guideline implementation was observed in both the new patient group and the patients with continuing prescription orders/treatment changes. There was also an improvement in patients whose prescriptions were dispensed by UI Health and to a lesser degree those whose prescriptions were dispensed by an outside pharmacy. When the new patient group was analyzed separately (n = 92), 50 patients were treated before the guidelines were implemented, and 42 patients were treated after the guidelines were implemented. Compliance rates with safety monitoring in these 2 groups were 52% pre-implementation and 83% post-implementation, which represented a statistically significant improvement in compliance (Pearson chi square = 10.03, df=1, P = 0.0015). Similar results were observed in the second patient subgroup with continuing prescription orders/treatment change (n = 228). A total of 123 patients were treated before the guidelines were implemented, and 105 were treated after the guidelines were implemented. Compliance rates were 23% pre-implementation compared with 50% post-implementation, which represented a statistically significant improvement in compliance (Pearson chi square = 18.99, df = 1, P  less than  0.0001). Given the widespread and long-term use of BRMs, safety monitoring and management should be an important part of a comprehensive medication management program for their use. A coordinated effort may have a significant impact on compliance with safety monitoring guidelines.

Do guidelines on first impression make sense? Implementation of a chest pain guideline in primary care: a systematic evaluation of acceptance and feasibility.

PubMed

Kramer, Lena; Rabanizada, Nagela; Haasenritter, Jörg; Bösner, Stefan; Baum, Erika; Donner-Banzhoff, Norbert

2011-11-21

Most guidelines concentrate on investigations, treatment, and monitoring instead of patient history and clinical examination. We developed a guideline that dealt with the different aetiologies of chest pain by emphasizing the patient's history and physical signs. The objective of this study was to evaluate the guideline's acceptance and feasibility in the context of a practice test. The evaluation study was nested in a diagnostic cross-sectional study with 56 General Practitioners (GPs) and 862 consecutively recruited patients with chest pain. The evaluation of the guideline was conducted in a mixed method design on a sub-sample of 17 GPs and 282 patients. Physicians' evaluation of the guideline was assessed via standardized questionnaires and case record forms. Additionally, practice nursing staff and selected patients were asked for their evaluation of specific guideline modules. Quantitative data was analyzed descriptively for frequencies, means, and standard deviations. In addition, two focus groups with a total of 10 GPs were held to gain further insights in the guideline implementation process. The data analysis and interpretation followed the standards of the qualitative content analysis. The overall evaluation of the GPs participating in the evaluation study regarding the recommendations made in the chest pain guideline was positive. A total of 14 GPs were convinced that there was a need for this kind of guideline and perceived the guideline recommendations as useful. While the long version was partially criticized for a perceived lack of clarity, the short version of the chest pain guideline and the heart score were especially appreciated by the GPs. However, change of clinical behaviour as consequence of the guideline was inconsistent. While on a concrete patient related level, GPs indicated to have behaved as the guideline recommended, the feedback on a more general level was heterogeneous. Several suggestions to improve guideline implementation were made by participating physicians. Due to the small number of practice nursing staff evaluating the flowchart and patients remembering the patient leaflet, no valid results regarding the flowchart and patient leaflet modules could be reported. Overall, the participating GPs perceived the guideline recommendations as useful to increase awareness and to reflect on diagnostic issues. Although behaviour change in consequence of the guideline was not reported on a general level, guidelines on history taking and the clinical examination may serve an important conservative and practical function in a technology driven environment. Further research to increase the implementation success of the guideline should be undertaken.

Implementation of Early Childhood Development Education Service Standard Guidelines on Physical Facilities in Public and Private Early Childhood Education Centres Kakamega County, Kenya

ERIC Educational Resources Information Center

Sitati, Emmily M.; Ndirangu, Mwangi; Kennedy, Bota; Rapongo, George S.

2016-01-01

In 2006, the Kenyan Ministry of Education (MoE) developed an early childhood development education (ECDE) service standard guidelines to guide the ECDE stakeholders in provision of early childhood education (ECE) programmes. The study sought to investigate the implementation of the ECDE service standard guidelines on provision of physical…

Implementation of a Multidisciplinary Guideline for Low Back Pain: Process-Evaluation Among Health Care Professionals.

PubMed

Suman, Arnela; Schaafsma, Frederieke G; Buchbinder, Rachelle; van Tulder, Maurits W; Anema, Johannes R

2017-09-01

Background To reduce the burden of low back pain (LBP) in the Netherlands, a multidisciplinary guideline for LBP has been implemented in Dutch primary care using a multifaceted implementation strategy targeted at health care professionals (HCPs) and patients. The current paper describes the process evaluation of the implementation among HCPs. Methods The strategy aimed to improve multidisciplinary collaboration and communication, and consisted of 7 components. This process evaluation was performed using the Linnan and Steckler framework. Data were collected using a mixed methods approach of quantitative and qualitative data. Results 128 HCPs participated in the implementation study, of which 96 participated in quantitative and 21 participated in qualitative evaluation. Overall dose delivered for this study was 89 %, and the participants were satisfied with the strategy, mostly with the multidisciplinary approach, which contributed to the mutual understanding of each other's disciplines and perspectives. While the training sessions did not yield any new information, the strategy created awareness of the guideline and its recommendations, contributing to positively changing attitudes and aiding in improving guideline adherent behaviour. However, many barriers to implementation still exist, including personal and practical factors, confidence, dependence and distrust issues among the HCPs, as well as policy factors (e.g. reimbursement systems). Conclusions The data presented in this paper have shown that the strategy that was used to implement the guideline in a Dutch primary care setting was feasible, especially when using a multidisciplinary approach. However, identified barriers for implementation have been identified and should be addressed in future implementation.

Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study.

PubMed

Milisen, Koen; Coussement, Joke; Arnout, Hanne; Vanlerberghe, Virginie; De Paepe, Leen; Schoevaerdts, Didier; Lambert, Margareta; Van Den Noortgate, Nele; Delbaere, Kim; Boonen, Steven; Dejaeger, Eddy

2013-04-01

About 40% of all adverse events in hospital are falls, but only about one in three Belgian hospitals have a fall prevention policy in place. The implementation of a national practice guideline is urgently needed. This multicentre study aimed to determine the feasibility of a previously developed guideline. SETTING, PARTICIPANTS AND METHOD: Seventeen geriatric wards, selected at random out of 40 Belgian hospitals who agreed to take part in the study, evaluated the fall prevention guideline. After the one-month test period, 49 healthcare workers completed a questionnaire on the feasibility of the guideline. At the end of the study, 512 geriatric patients had been assessed using the practice guideline. The average time spent per patient on case finding, multifactorial assessment and initiating a treatment plan was 5.1, 76.1 and 30.6 min, respectively. For most risk assessments and risk modifications, several disciplines considered themselves as being responsible and capable. The majority (more than 69%) of the respondents judged the practice guideline as useful, but only a small majority (62.3%) believed that the guideline could be successfully integrated into their daily practice over a longer period of time. Barriers for implementation included a large time investment (81.1%), lack of communication between the different disciplines (35.8%), lack of motivation of the patient (34.0%), lack of multidisciplinary teamwork (28.3%), and lack of interest from the hospital management (15.4%). Overall, the guideline was found useful, and for each risk factor (except for visual impairment), at least one discipline felt responsible and capable. Towards future implementation of the guideline, following steps should be considered: division of the risk-factor assessment duties and interventions among different healthcare workers; patient education; appointment of a fall prevention coordinator; development of a fall prevention policy with support from the management of the hospital. Copyright © 2012 Elsevier Ltd. All rights reserved.

Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay.

PubMed

Souza Possa, S; Braga Amador, C; Meira Costa, A; Takahama Sakamoto, E; Seiko Kondo, C; Maida Vasconcellos, A L; Moran de Brito, C M; Pereira Yamaguti, W

2014-01-01

The aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS) in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. A "before and after" study design with historical control was used. The "before" period included consecutive patients who underwent UAS before guideline implementation (intervention). The "after" period included consecutive patients after guideline implementation. Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization). There was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post-intervention period. No patient who adhered totally to the guideline in the post-intervention period developed atelectasis. Individuals in the post-intervention period presented a shorter length of hospital stay (9.2±4.1 days) compared to patients in the pre-intervention period (12.1±8.3 days) (p<0.05). The implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period. Copyright © 2013 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.

Could accreditation bodies facilitate the implementation of medical guidelines in laboratories?

PubMed

Aakre, Kristin M; Oosterhuis, Wytze P; Misra, Shivani; Langlois, Michel R; Joseph, Watine; Twomey, Patrick J; Barth, Julian H

2017-05-01

Several studies have shown that recommendations related to how laboratory testing should be performed and results interpreted are limited in medical guidelines and that the uptake and implementation of the recommendations that are available need improvement. The EFLM/UEMS Working Group on Guidelines conducted a survey amongst the national societies for clinical chemistry in Europe regarding development of laboratory-related guidelines. The results showed that most countries have guidelines that are specifically related to laboratory testing; however, not all countries have a formal procedure for accepting such guidelines and few countries have guideline committees. Based on this, the EFLM/UEMS Working Group on Guidelines conclude that there is still room for improvement regarding these processes in Europe and raise the question if the accreditation bodies could be a facilitator for an improvement.

Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.

PubMed

Bernhardsson, Susanne; Larsson, Maria E H; Eggertsen, Robert; Olsén, Monika Fagevik; Johansson, Kajsa; Nilsen, Per; Nordeman, Lena; van Tulder, Maurits; Öberg, Birgitta

2014-03-04

Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden. An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson's χ2 test and approximative z-test. 168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes. A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Managing peripheral venous catheters: an investigation on the efficacy of a strategy for the implementation of evidence-based guidelines.

PubMed

Frigerio, Simona; Di Giulio, Paola; Gregori, Dario; Gavetti, Dario; Ballali, Simonetta; Bagnato, Silvia; Guidi, Gabriella; Foltran, Francesca; Renga, Giovanni

2012-04-01

Until now, the evaluation of the effectiveness of guideline implementation in nursing and allied health professions has received relatively little attention. The aims of this study were (i) to describe the development process of guidelines concerning the management of peripheral venous catheters (PVCs) implemented in an Italian hospital; and (ii) to evaluate the effectiveness of guideline dissemination in terms of both clinical outcomes (signs of infection) and process outcomes (measures of appropriateness of PVC management). An observational study was conducted before and after the adoption of a new protocol in the CTO-CRF-Maria Adelaide Hospital. Data from 306 PVCs (153 before and 153 after) were collected. For each PVC, a wide range of outcome measures was collected, including: data on fixation system type of dressing; visibility of the insertion site; registration of the insertion date; duration of catheter insertion; presence of connectors, taps and needles; and signs of infection. The effect of guideline implementation was evaluated using a logistic regression model to adjust for the confounding variable represented by the nurses' average years of working experience. The risk of using inappropriate dressing was significantly reduced [odds ratio (OR) 0.43; 95% confidence interval (CI) 0.27-0.70], while the use of transparent dressing increased (OR 2.39; 95% CI 1.46-3.89). Our study shows significant improvement in practices relevant to the correct management of PVCs 2 months after guideline implementation. A second survey (after a minimum of 6 months) is necessary to assess persistence of improvement in clinical practices. © 2010 Blackwell Publishing Ltd.

Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps.

PubMed

Hawkins, Russell B; Levy, Shauna M; Senter, Casey E; Zhao, Jane Y; Doody, Kaitlin; Kao, Lillian S; Lally, Kevin P; Tsao, KuoJen

2013-10-01

Despite increased compliance with Surgical Care Improvement Project infection measures, surgical-site infections are not decreasing. The aim of this study was to test the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect implementation fidelity or adherence to guidelines as intended. A 7-week observational study of elective pediatric surgical cases was conducted. Adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases (70%) in which antibiotic prophylaxis was indicated, compliance was documented in 100% cases in the electronic medical record, but only 48% of cases adhered to all 5 guidelines. Lack of adherence was due primarily to dosing or timing errors. Lack of implementation fidelity in antibiotic prophylaxis guidelines may partly explain the lack of expected reduction in surgical-site infections. Future studies of Surgical Care Improvement Project effectiveness should measure adherence and implementation fidelity rather than just documented compliance. Copyright © 2013 Elsevier Inc. All rights reserved.

A new impetus for guideline development and implementation: construction and evaluation of a toolbox.

PubMed

Hilbink, Mirrian A H W; Ouwens, Marielle M T J; Burgers, Jako S; Kool, Rudolf B

2014-03-19

In the last decade, guideline organizations faced a number of problems, including a lack of standardization in guideline development methods and suboptimal guideline implementation. To contribute to the solution of these problems, we produced a toolbox for guideline development, implementation, revision, and evaluation. All relevant guideline organizations in the Netherlands were approached to prioritize the topics. We sent out a questionnaire and discussed the results at an invitational conference. Based on consensus, twelve topics were selected for the development of new tools. Subsequently, working groups were composed for the development of the tools. After development of the tools, their draft versions were pilot tested in 40 guideline projects. Based on the results of the pilot tests, the tools were refined and their final versions were presented. The vast majority of organizations involved in pilot testing of the tools reported satisfaction with using the tools. Guideline experts involved in pilot testing of the tools proposed a variety of suggestions for the implementation of the tools. The tools are available in Dutch and in English at a web-based platform on guideline development and implementation (http://www.ha-ring.nl). A collaborative approach was used for the development and evaluation of a toolbox for development, implementation, revision, and evaluation of guidelines. This approach yielded a potentially powerful toolbox for improving the quality and implementation of Dutch clinical guidelines. Collaboration between guideline organizations within this project led to stronger linkages, which is useful for enhancing coordination of guideline development and implementation and preventing duplication of efforts. Use of the toolbox could improve quality standards in the Netherlands, and might facilitate the development of high-quality guidelines in other countries as well.

Practice organisational characteristics can impact on compliance with the BTS/SIGN asthma guideline: qualitative comparative case study in primary care.

PubMed

Wiener-Ogilvie, Sharon; Huby, Guro; Pinnock, Hilary; Gillies, John; Sheikh, Aziz

2008-06-04

Although the BTS-SIGN asthma guideline is one of the most well known and widely respected guidelines in the world, implementation in UK primary care remains patchy. Building on extensive earlier descriptive work, we sought to explore the way teamwork and inter-professional relationships impact on the implementation of the BTS-SIGN guideline on asthma in general practice. Qualitative comparative case study using nine in-depth interviews and 2 focus groups with general practitioners and practice nurses, involved in delivering asthma care. Participants were purposively recruited from practices in a Scottish health board with high and low compliance with the BTS-SIGN asthma guideline. There was a marked difference in the way respondents from practices with high compliance and respondents from practices with low compliance spoke about the value of guidelines and the challenges of implementing them. On both accounts, the former were more positive than the latter and were able to be more specific about the strategies they used to overcome barriers to implementation. We explored the reason for this difference in response and identified practice organisation, centring on delegation of work to nurses, as a factor mediating the practice's level of compliance. Effective delegation was underpinned by organisation of asthma work among practice members who have the appropriate level of skills and knowledge, know and understand each others' work and responsibilities, communicate well among themselves and trust each others' skills. It was the combination of these factors which made for successful delegation and guideline implementation, not any one factor in isolation. In our sample of practices, teamwork and organisation of care within practices appeared to impact on guideline implementation and further larger studies are needed to explore this issue further. Isolated interventions such as measures to improve staff's knowledge or increased clinical resource and time, which are currently being considered, are unlikely to be effective unless practices are supported in developing their teams in a way which supports the deployment of these resources.

Implementation of NCCN Palliative Care Guidelines by member institutions.

PubMed

Albizu-Rivera, Alexandra; Portman, Diane G; Thirlwell, Sarah; Codada, Shirley N; Donovan, Kristine A

2016-02-01

Increasingly, evidence suggests the integration of palliative care (PC) with standard oncologic care can yield substantial benefits. As part of an effort to improve the PC of cancer patients, the National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines for PC that promote access to quality, evidence-based PC. This study sought to characterize current implementation of the guidelines by NCCN member institutions. Institutional representatives appointed to the NCCN Palliative Care Guidelines Panel were asked to complete an online survey in the spring of 2014. The survey focused on availability of PC services, screening and referral practices for PC, PC education, and quality improvement programs. The survey was completed by representatives from 21 of 25 NCCN member institutions (84 %). A majority routinely provides PC services via interdisciplinary teams; 52 % routinely inform patients of the availability, elements, and benefits of PC. The guidelines are most often used to guide clinical practice; only 10 % reported using the guidelines to formally screen for PC needs and/or make referrals to PC specialists. Among the 62 % of institutions that screen any patients using any available criteria, when a patient screens positive for PC needs, a referral to a PC specialist is made less than half the time. Implementation of PC Guidelines is incomplete and various aspects of the guidelines, such as the recommendation to screen all patients for PC needs, are applied inconsistently. Despite this, most institutions provide PC services in a manner consistent with the guidelines. Greater implementation of the guidelines' recommendations is needed.

Pre-implementation guidelines for infectious disease point-of-care testing in medical institutions.

PubMed

van der Eijk, Annemiek A; Tintu, Andrei N; Hays, John P

2017-01-01

Infectious disease point-of-care test (ID-POCT) devices are becoming widely available, and in this respect, international quality standards and guidelines are available for consultation once ID-POCT has been implemented into medical institutions. However, specific guidelines for consultation during the initial pre-implementation decision-making process are currently lacking. Further, there exist pre-implementation issues specific to ID-POCT. Here we present pre-implementation guidelines for consultation when considering the implementation of ID-POCT in medical institutions.

Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

PubMed

Grimshaw, Jeremy M; Schünemann, Holger J; Burgers, Jako; Cruz, Alvaro A; Heffner, John; Metersky, Mark; Cook, Deborah

2012-12-01

Professional societies, like many other organizations around the world, have recognized the need to use rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the thirteenth of a series of 14 articles that were prepared to advise guideline developers in respiratory and other diseases. This article focuses on current concepts and research evidence about how to disseminate and implement guidelines optimally on a national and international level to improve quality of care. In this article we address the following questions: What frameworks can aid guideline dissemination and implementation; what are the effects of different guideline dissemination and implementation strategies; and, what is the role of guideline developers in guideline dissemination and implementation? We identified existing systematic reviews and relevant methodological research. Our conclusions are based on evidence from published literature, experience from guideline developers, and workshop discussions. The Knowledge to Action cycle proposed by Graham and colleagues (J Contin Educ Health Prof 2006;26:13-24) provides a useful framework for planning dissemination and implementation activities that emphasize the need for tailored approaches based on an assessment of local barriers. There are a broad range of interventions that are generally effective at improving the uptake of evidence. The best intervention depends on likely barriers, available resources, and other practical considerations. Financial interventions (such as pay for performance) appear to be as effective as other interventions that aim to change professional behavior. Guideline developers who do not have responsibility for guideline implementation in their jurisdiction should support those with responsibility for implementation by considering the "implementability" of their guidelines.

Reduction of Broad-Spectrum Antimicrobial Use in a Tertiary Children's Hospital Post Antimicrobial Stewardship Program Guideline Implementation.

PubMed

Lee, Kelley R; Bagga, Bindiya; Arnold, Sandra R

2016-03-01

The core strategies recommended for antimicrobial stewardship programs, formulary restriction with preauthorization and prospective audit and feedback, can be difficult to implement with limited resources; therefore, we took an approach of guideline development and education with the goal of reducing overall antibiotic use and unwarranted use of broad-spectrum antimicrobials. Retrospective chart review before and after intervention. Le Bonheur Children's Hospital pediatric, neonatal, and cardiac ICUs. All patients in our pediatric, neonatal, and cardiac ICUs within the time frame of the study. Baseline review in our ICUs revealed excessive use of broad-spectrum antibiotics and inconsistency in managing common pediatric infections. Guidelines were developed and implemented using cycles of education, retrospective review, and feedback. Purchasing and antibiotic use data were obtained to assess changes before and after guideline implementation. Unit-specific days of therapy were measured using periodic chart audit. Segmented regression analysis was used to assess changes in purchasing and broad-spectrum antibiotic days of therapy. The change in median monthly purchases was assessed using 2-tail Student t test. Hospital-wide targeted broad-spectrum antibiotic days of therapy/1,000 patient-days during the preimplementation year averaged 105 per month and decreased 33% to 70 per month during the postimplementation year. The overall antibiotic days of therapy decreased 41%, 21%, and 18%, and targeted broad-spectrum antibiotic days of therapy decreased by 99%, 75%, and 61% in the cardiac, pediatric, and neonatal ICUs, respectively, after guideline implementation. Yearly purchases of our most common broad-spectrum antibiotics decreased 62% from $230,059 to $86,887 after guideline implementation. Median monthly purchases of these drugs before implementation were $19,389 and $11,043 after implementation (p < 0.001). Guideline implementation was successful in reducing targeted broad-spectrum antibiotic use and acquisition cost. Programs with very limited resources may find similar implementation of guidelines effective to provide initial success, so that putting into practice one of the more resource intensive core strategies, such as prospective audit and feedback, may be feasible.

Number and type of guideline implementation tools varies by guideline, clinical condition, country of origin, and type of developer organization: content analysis of guidelines.

PubMed

Liang, Laurel; Abi Safi, Jhoni; Gagliardi, Anna R

2017-11-15

Guideline implementation tools (GI tools) can improve clinician behavior and patient outcomes. Analyses of guidelines published before 2010 found that many did not offer GI tools. Since 2010 standards, frameworks and instructions for GI tools have emerged. This study analyzed the number and types of GI tools offered by guidelines published in 2010 or later. Content analysis and a published GI tool framework were used to categorize GI tools by condition, country, and type of organization. English-language guidelines on arthritis, asthma, colorectal cancer, depression, diabetes, heart failure, and stroke management were identified in the National Guideline Clearinghouse. Screening and data extraction were in triplicate. Findings were reported with summary statistics. Eighty-five (67.5%) of 126 eligible guidelines published between 2010 and 2017 offered one or more of a total of 464 GI tools. The mean number of GI tools per guideline was 5.5 (median 4.0, range 1 to 28) and increased over time. The majority of GI tools were for clinicians (239, 51.5%), few were for patients (113, 24.4%), and fewer still were to support implementation (66, 14.3%) or evaluation (46, 9.9%). Most clinician GI tools were guideline summaries (116, 48.5%), and most patient GI tools were condition-specific information (92, 81.4%). Government agencies (patient 23.5%, clinician 28.9%, implementation 24.1%, evaluation 23.5%) and developers in the UK (patient 18.5%, clinician 25.2%, implementation 27.2%, evaluation 29.1%) were more likely to generate guidelines that offered all four types of GI tools. Professional societies were more likely to generate guidelines that included clinician GI tools. Many guidelines do not include any GI tools, or a variety of GI tools for different stakeholders that may be more likely to prompt guideline uptake (point-of-care forms or checklists for clinicians, decision-making or self-management tools for patients, implementation and evaluation tools for managers and policy-makers). While this may vary by country and type of organization, and suggests that developers could improve the range of GI tools they develop, further research is needed to identify determinants and potential solutions. Research is also needed to examine the cost-effectiveness of various types of GI tools so that developers know where to direct their efforts and scarce resources.

Perceptions of national guidelines and their (non) implementation in mental healthcare: a deductive and inductive content analysis.

PubMed

Sandström, Boel; Willman, Ania; Svensson, Bengt; Borglin, Gunilla

2015-04-01

National guidelines are being produced at an increasing rate, and politicians and managers are expected to promote these guidelines and their implementation in clinical work. However, research seldom deals with how decision-makers can perceive these guidelines or their challenges in a cultural context. Therefore, the aim of this study was twofold: to investigate how well Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of mental healthcare and to gain an extended understanding of the perceptions of decision-makers operating within this context, in regard to the implementation of evidence-based guidelines. The study took place in the southeast of Sweden and employed a qualitative design. The data were collected through 23 interviews with politicians and managers working either in the county council or in the municipalities. The transcribed text was analysed iteratively and in two distinct phases, first deductively and second inductively by means of qualitative content analysis. Our deductive analysis showed that the text strongly reflected two out of three categorisation matrices, i.e. evidence and context representing the PARIHS framework. However, the key element of facilitation was poorly mirrored in the text. Results from the inductive analysis can be seen in light of the main category sitting on the fence; thus, the informants' perceptions reflected ambivalence and contradiction. This was illustrated by conflicting views and differences in culture and ideology, a feeling of security in tradition, a certain amount of resistance to change and a lack of role clarity and clear directions. Together, our two analyses provide a rich description of an organisational culture that is highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in stark contrast to the high confidence in the knowledge of experienced people in authority within the organisational context. Our findings have highlighted that, regardless of by whom guidelines are released, they are not likely to be utilised or implemented if those who are responsible for implementing them do not trust the source. This aspect (i.e. contextual trust) is not covered by PARIHS.

Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study.

PubMed

Mangino, Julie E; Peyrani, Paula; Ford, Kimbal D; Kett, Daniel H; Zervos, Marcus J; Welch, Verna L; Scerpella, Ernesto G; Ramirez, Julio A

2011-01-01

In 2005 the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) published guidelines for managing hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP). Although recommendations were evidence based, collective guidelines had not been validated in clinical practice and did not provide specific tools for local implementation. We initiated a performance improvement project designated Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) at four academic centers in the United States. Our objectives were to develop and implement the project, and to assess compliance with quality indicators in adults admitted to intensive care units (ICUs) with HAP, VAP, or HCAP. The project was conducted in three phases over 18 consecutive months beginning 1 February 2006: 1) a three-month planning period for literature review to create the consensus pathway for managing nosocomial pneumonia in these ICUs, a data collection form, quality performance indicators, and internet-based repository; 2) a six-month implementation period for customizing ATS/IDSA guidelines into center-specific guidelines via educational forums; and 3) a nine-month post-implementation period for continuing education and data collection. Data from the first two phases were combined (pre-implementation period) and compared with data from the post-implementation period. We developed a consensus pathway based on ATS/IDSA guidelines and customized it at the local level to accommodate formulary and microbiologic considerations. We implemented multimodal educational activities to teach ICU staff about the guidelines and continued education throughout post-implementation. We registered 432 patients (pre- vs post-implementation, 274 vs 158). Diagnostic criteria for nosocomial pneumonia were more likely to be met during post-implementation (247/257 (96.1%) vs 150/151 (99.3%); P = 0.06). Similarly, empiric antibiotics were more likely to be compliant with ATS/IDSA guidelines during post-implementation (79/257 (30.7%) vs 66/151 (43.7%); P = 0.01), an effect that was sustained over quarterly intervals (P = 0.0008). Between-period differences in compliance with obtaining cultures and use of de-escalation were not statistically significant. Developing a multi-center performance improvement project to operationalize ATS/IDSA guidelines for HAP, VAP, and HCAP is feasible with local consensus pathway directives for implementation and with quality indicators for monitoring compliance with guidelines.

Guidelines for the management of hepatitis C in general practice: a semi-qualitative interview survey of GPs' views regarding content and implementation.

PubMed

Cullen, W; O'Leary, M; Langton, D; Stanley, J; Kelly, Y; Bury, G

2005-01-01

Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment. To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation. A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines. GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation. Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.

[Implementation of clinical practice guidelines: how can we close the evidence-practice gap?].

PubMed

Muche-Borowski, Cathleen; Nothacker, M; Kopp, I

2015-01-01

Guidelines are intended as instruments of knowledge transfer to support decision-making by physicians, other health professionals and patients in clinical practice and thereby contribute to quality improvements in healthcare. To date they are an indispensable tool for healthcare. Their benefit for patients can only be seen in application, i.e. the implementation of guideline recommendations. For successful implementation, implementability and practicability play a crucial role and these characteristics can be influenced and should be promoted by the guideline development group. In addition, a force field analysis to identify barriers against and facilitators for the implementation of specific guideline recommendations from the perspective of physicians and patients is recommended to guide the development of an individual implementation strategy and the selection of appropriate interventions. However, implementation cannot be achieved by the guideline development group alone and a universal implementation strategy does not exist. Therefore, a process using theory, analysis, experience and shared responsibility of stakeholders in healthcare is recommended, with the aim to achieve sustainable behavioral change and improve the quality of care by guideline-oriented behavior.

Multi-faceted implementation strategy to increase use of a clinical guideline for the diagnosis of deep venous thrombosis in primary care.

PubMed

Kingma, Anna E C; van Stel, Henk F; Oudega, Ruud; Moons, Karel G M; Geersing, Geert-Jan

2017-08-01

A clinical decision rule (CDR), combined with a negative D-dimer test, can safely rule out deep venous thrombosis (DVT) in primary care. This strategy is recommended by guidelines, yet uptake by GPs is low. To evaluate a multi-faceted implementation strategy aimed at increased use of the guideline recommended CDR plus D-dimer test in primary care patients with suspected DVT. This multi-faceted implementation strategy consisted of educational outreach visits, financial reimbursements and periodical newsletters. 217 Dutch GPs (implementation group) received this strategy and included patients. Effectiveness was measured through the following patient-level outcomes: (i) proportion of non-referred patients, (ii) proportion of missed DVT cases within this group and (iii) the proportion of patients in whom the guideline was applied incorrectly. Implementation outcomes ('acceptability', 'feasibility', 'fidelity' and 'sustainability') were assessed with an online questionnaire. Patient-level outcomes were compared with those of patients included by 450 GPs, uninformed about the study's purposes providing information about usual care. 336 (54%) of 619 analyzable implementation group patients were not referred, missing 6 [1.8% (95% confidence interval 0.7% to 3.9%)] DVT cases. Incorrect guideline use was observed in 199 patients (32%). Self-reported acceptability, feasibility and expected sustainability were high. Guideline use increased from 42% to an expected continuation of use of 91%. Only 32 usual care GPs included 62 patients, making formal comparison unreliable. This multi-faceted implementation strategy safely reduced patient referral to secondary care, despite frequently incorrect application of the guideline and resulted in high acceptability, feasibility and expected sustainability. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Reporting guidelines for implementation and operational research.

PubMed

Hales, Simon; Lesher-Trevino, Ana; Ford, Nathan; Maher, Dermot; Ramsay, Andrew; Tran, Nhan

2016-01-01

In public health, implementation research is done to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them. Researchers identify practical problems facing public health programmes and aim to find solutions that improve health outcomes. In operational research, routinely-collected programme data are used to uncover ways of delivering more effective, efficient and equitable health care. As implementation research can address many types of questions, many research designs may be appropriate. Existing reporting guidelines partially cover the methods used in implementation and operational research, so we ran a consultation through the World Health Organization (WHO), the Alliance for Health Policy & Systems Research (AHPSR) and the Special Programme for Research and Training in Tropical Diseases (TDR) and developed guidelines to facilitate the funding, conduct, review and publishing of such studies. Our intention is to provide a practical reference for funders, researchers, policymakers, implementers, reviewers and editors working with implementation and operational research. This is an evolving field, so we plan to monitor the use of these guidelines and develop future versions as required.

Requirements for guidelines systems: implementation challenges and lessons from existing software-engineering efforts.

PubMed

Shah, Hemant; Allard, Raymond D; Enberg, Robert; Krishnan, Ganesh; Williams, Patricia; Nadkarni, Prakash M

2012-03-09

A large body of work in the clinical guidelines field has identified requirements for guideline systems, but there are formidable challenges in translating such requirements into production-quality systems that can be used in routine patient care. Detailed analysis of requirements from an implementation perspective can be useful in helping define sub-requirements to the point where they are implementable. Further, additional requirements emerge as a result of such analysis. During such an analysis, study of examples of existing, software-engineering efforts in non-biomedical fields can provide useful signposts to the implementer of a clinical guideline system. In addition to requirements described by guideline-system authors, comparative reviews of such systems, and publications discussing information needs for guideline systems and clinical decision support systems in general, we have incorporated additional requirements related to production-system robustness and functionality from publications in the business workflow domain, in addition to drawing on our own experience in the development of the Proteus guideline system (http://proteme.org). The sub-requirements are discussed by conveniently grouping them into the categories used by the review of Isern and Moreno 2008. We cite previous work under each category and then provide sub-requirements under each category, and provide example of similar work in software-engineering efforts that have addressed a similar problem in a non-biomedical context. When analyzing requirements from the implementation viewpoint, knowledge of successes and failures in related software-engineering efforts can guide implementers in the choice of effective design and development strategies.

Requirements for guidelines systems: implementation challenges and lessons from existing software-engineering efforts

PubMed Central

2012-01-01

Background A large body of work in the clinical guidelines field has identified requirements for guideline systems, but there are formidable challenges in translating such requirements into production-quality systems that can be used in routine patient care. Detailed analysis of requirements from an implementation perspective can be useful in helping define sub-requirements to the point where they are implementable. Further, additional requirements emerge as a result of such analysis. During such an analysis, study of examples of existing, software-engineering efforts in non-biomedical fields can provide useful signposts to the implementer of a clinical guideline system. Methods In addition to requirements described by guideline-system authors, comparative reviews of such systems, and publications discussing information needs for guideline systems and clinical decision support systems in general, we have incorporated additional requirements related to production-system robustness and functionality from publications in the business workflow domain, in addition to drawing on our own experience in the development of the Proteus guideline system (http://proteme.org). Results The sub-requirements are discussed by conveniently grouping them into the categories used by the review of Isern and Moreno 2008. We cite previous work under each category and then provide sub-requirements under each category, and provide example of similar work in software-engineering efforts that have addressed a similar problem in a non-biomedical context. Conclusions When analyzing requirements from the implementation viewpoint, knowledge of successes and failures in related software-engineering efforts can guide implementers in the choice of effective design and development strategies. PMID:22405400

What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists?

PubMed

Mudge, Suzie; Hart, Anna; Murugan, Sankaran; Kersten, Paula

2017-03-01

Purpose To explore perceived barriers and facilitators to the use of the New Zealand (NZ) stroke guidelines by occupational therapists and physiotherapists. Methods A qualitative descriptive methodology was used. Eligible physiotherapists and occupational therapists (NZ registered, working in one of two hospitals, treating at least 10 patients with stroke in the previous year) were invited to participate in semi-structured interviews to elicit their perceptions of the utility and feasibility of the NZ stroke guidelines and identify barriers and facilitators to their implementation. All interviews were audio-recorded and transcribed. Conventional content analysis with constant comparative methods was used for coding and analysis. Results The main themes influencing guideline implementation were resources and characteristics of the guidelines, the organization, the patient and family and the therapist. Insufficient resources were a major barrier that crossed many of the themes. Participants suggested a range of strategies relating to the organization to improve therapists' alignment to the guidelines. Conclusion Alignment to the guidelines in NZ is influenced both positively and negatively by a range of interacting factors, consistent with other studies. Alignment might be improved by the introduction of some relatively simple strategies, such as ring-fencing time for access to resources and training in the use of the guidelines. Many of the barriers and related interventions are likely to be more complex. Implications for rehabilitation Alignment with stroke guidelines has been shown to improve patient outcomes. Therapist alignment with the implementation of the New Zealand stroke guidelines is influenced by guideline characteristics, organizational characteristics, resources, patient and family characteristics and therapist characteristics. Frequently encountered barriers related to limited resources, particularly time. Ring-fencing regular time for access to resources and training in the use of guidelines are examples of simple strategies that may reduce barriers.

Clinical and economic evaluation of an evidence-based institutional epoetin-utilization management program.

PubMed

Buckley, Mitchell S; Kane-Gill, Sandra L; Patel, Shardool A

2013-03-01

Anemia is common in several patient populations, including those with chronic kidney disease, cancer, and HIV/AIDS, and may require treatment with erythropoietin-stimulating agents (ESAs). Given the potential risks of the ESA, epoetin, and the significant costs associated with this agent, a large teaching medical institution developed a the drug-utilization management program using evidence-based guidelines on appropriate use. This study was designed to determine the clinical and financial impact of the drug-utilization management program. This retrospective cohort study was conducted at the medical institution that implemented the program using clinical pharmacists. Patients were included if epoetin was administered during their hospital stay (evaluation period, December 1, 2010, to December 31, 2011). The rate of inappropriate epoetin prescribing and the economic impact of guideline implementation were evaluated using comparisons of data from cohorts prescribed epoetin before and after guideline implementation. Data from 796 patients were included in the analyses (pre-implementation, 496; post-implementation, 300). The proportion of patients prescribed epoetin was significantly smaller after guideline implementation (2.4% vs 1.6%; P < 0.001). The reduction in the total number of epoetin units administered was 45%. The significant reduction (25%) in inappropriate prescribing after guideline implementation was primarily attributed to a 17% decrease in epoetin use in nonspecific anemia. The reduction in inappropriate epoetin prescribing translated into a 23.8% reduction in costs (P < 0.001) associated with inappropriate epoetin use. The estimated annual cost-savings of this program was $198,352 ($16,529/mo). The implementation of a drug-utilization management program using clinical pharmacists who evaluated epoetin was associated with a decrease in inappropriate epoetin prescribing and with significant cost-savings. Copyright © 2013 Elsevier HS Journals, Inc. All rights reserved.

Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial

PubMed Central

2014-01-01

Background Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden. Methods An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test. Results 168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes. Conclusions A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected. PMID:24589291

Symptom relief in patients with pneumonia and dementia: implementation of a practice guideline.

PubMed

van der Maaden, Tessa; van der Steen, Jenny T; Koopmans, Raymond T C M; Doncker, Sarah M M M; Anema, Johannes R; Hertogh, Cees M P M; de Vet, Henrica C W

2017-08-01

This study aimed to assess the degree of implementation and barriers encountered in the use of a practice guideline for optimal symptom relief for patients with dementia and pneumonia in Dutch nursing homes. A process evaluation included assessment of reach, fidelity, and dose delivered using researcher's observations, and dose received was addressed in a question "use of the practice guideline," which the physicians completed for each patient included in the study. Perceived barriers were assessed with a structured questionnaire (response 69%) and semi-structured interviews (n = 14), which were subject to qualitative content analysis. Of the 55 physicians involved in the intervention phase, 87% attended an implementation meeting; 20 physicians joined the study later (reach). The intervention was implemented as planned, and all intervention components were delivered by the researchers (fidelity and dose delivered). Thirty-six physicians included 109 patients. For 81% of the patients, the treating physician stated to have used the guideline (dose received). The guideline was perceived as providing a good overview of current practice, but some physicians had expected a more directive protocol or algorithm. Further, recommended regular observations of symptoms were rarely performed. Physician's often felt that "this is not different from what we usually do," and with the acute illness, there was not always enough time to (re)familiarize with the contents. The physicians used the practice guideline frequently despite important barriers. Future implementation may involve strategies such as multiple interactive meetings. Further, the greatest potential to alter usual practice should be emphasized, such as using observational instruments. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Critical appraisal of clinical practice guidelines in pediatric infectious diseases.

PubMed

Wilby, Kyle John; Black, Emily Kathleen; MacLeod, Claire; Wiens, Matthew; Lau, Tim T Y; Paiva, Maria A; Gorman, Sean

2015-10-01

There is a need to critically appraise clinical practice guidelines in order to ensure safe and effective practices are being implemented to optimize patient care. Appraising guidelines within one therapeutic area enable recommendations for improvement during guideline creation and dissemination. Study objectives were to systematically appraise selected published guidelines used in the treatment of pediatric infectious diseases and to make recommendations for improvement throughout the development and dissemination processes. The study occurred between collaborative academic and practice-based institutions located in Canada and Qatar. A literature search identified guidelines for management of pediatric infectious diseases from 1997 to 2013. Each guideline was appraised by four independent assessors, according to the appraisal of guidelines for research and evaluation II (AGREE II) instrument. Standardized domain scores were calculated for each guideline and pooled. Final endorsements for use in clinical practice were also determined. Inter-rater reliability was assessed using intraclass correlation coefficients. Standardized domain scores according to the AGREE II instrument. Twenty guidelines met inclusion criteria and were appraised. Pooled domain scores were: scope and purpose (69.9), stakeholder involvement (40.1), rigour of development (47.1), clarity of presentation (73.4), applicability (23.7), editorial independence (46.7), and overall assessment (55.8). Two (10%) guidelines were recommended for use without revision, 13 (65%) guidelines were recommended with modifications, and 5 (25%) guidelines were not recommended for implementation into practice. Inter-rater reliability was moderate to good with intra-class correlations of 0.65-0.93 per guideline. The majority of appraised guidelines were moderately rated, with a 25% of guidelines not recommended for use. Strategies for improvement require the involvement of all key stakeholders (caregivers, patients, and allied health professionals), and consideration of facilitators, barriers and resource implications during implementation. Additionally, critical appraisal of guidelines should become standard practice prior to adoption into clinical settings.

Peripheral amiodarone-related phlebitis: an institutional nursing guideline to reduce patient harm.

PubMed

Spiering, Mary

2014-01-01

Intravenous amiodarone is one of the most widely used antiarrythmics for the treatment of atrial fibrillation with rapid ventricular response. Peripheral amiodarone infusion, however, often causes pain during infusion and subsequent phlebitis.Data collection on a cardiac telemetry unit revealed a high rate of phlebitis. A multidisciplinary team developed and implemented amiodarone peripheral infusion guidelines. The pre-guideline phlebitis rate was 85% and post-guideline rate was 38%, representing a 47% change or improvement. An additional finding was that the severity of phlebitis was reduced, as well. The results of this study suggest that the implementation of a peripheral amiodarone infusion guideline reduced the incidence and severity of amiodarone-related phlebitis in the cardiac population.

Adherence of healthcare professionals to evidence-based clinical practice guidelines in the management of hemodialysis patients, Khartoum State, Sudan.

PubMed

Abdelwahab, Hisham; Shigidi, Mazin; El-Tohami, Alyaa; Ibrahim, Lamees

2013-05-01

Hemodialysis (HD) is a complex procedure with many specifications and requires adherence to a set of particular clinical practice guidelines. These guidelines had already been established by globally acclaimed renal authorities and their implementation was shown to correlate with patients' morbidity and mortality. This study was conducted to evaluate the adherence of healthcare professionals to the evidence-based clinical practice patterns in Khartoum State HD units. A cross-sectional study was conducted in Khartoum State HD units during the period from September 2010 to January of 2011. Data was collected from the healthcare professionals using a specially designed checklist. The checklist included the evidence-based clinical practice guidelines for the HD vascular access, HD adequacy, anemia of chronic kidney disease (CKD), nutrition, cardiovascular risk assessment, and hepatitis B and C virus infection control. Implementation of these guidelines was evaluated, and further graded using a Likert-type scale. Four randomly selected HD units were included in the study. The rate of implementation of the HD vascular access guidelines was 54.8%, adequacy guidelines 57%, anemia of CKD 68.8%, nutrition 58.4%, cardiovascular risk assessment 57%, and hepatitis B and C infection control guidelines was 79.2%. Overall, the four HD units assessed showed moderate deviations from the practice guidelines of anemia of CKD and hepatitis B and C infection control. Extreme deviations from the clinical practice guidelines were seen in HD vascular access practices, adequacy assessments, nutrition and cardiovascular risk assessment. Hemodialysis services in Khartoum State are in need of great improvements regarding adherence to protocols and the standards of care.

Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation.

PubMed

Shiffman, Richard N; Michel, George; Essaihi, Abdelwaheb; Thornquist, Elizabeth

2004-01-01

A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge.

Implementation of treatment guidelines for specialist mental health care.

PubMed

Barbui, Corrado; Girlanda, Francesca; Ay, Esra; Cipriani, Andrea; Becker, Thomas; Koesters, Markus

2014-01-17

A huge gap exists between the production of evidence and its take-up in clinical practice settings. To fill this gap, treatment guidelines, based on explicit assessments of the evidence base, are commonly employed in several fields of medicine, including schizophrenia and related psychotic disorders. It remains unclear, however, whether treatment guidelines have any impact on provider performance and patient outcomes, and how implementation should be conducted to maximise benefit. The primary objective of this review was to examine the efficacy of guideline implementation strategies in improving process outcomes (performance of healthcare providers) and patient outcomes. We additionally explored which components of different guideline implementation strategies can influence process and patient outcomes. We searched the Cochrane Schizophrenia Group Register (March 2012), as well as references of included studies. Studies that examined schizophrenia-spectrum disorders to compare guideline implementation strategies with usual care or to assess the comparative efficacy of different guideline implementation strategies. Review authors worked independently and in duplicate to critically appraise records from 882 studies; five individual studies met the inclusion criteria and were considered. As critical appraisal of the five included studies revealed substantial heterogeneity in terms of focus of the guideline, target of the intervention, implementation strategy and outcome measures, meta-analysis was carried out for antipsychotic co-prescribing only. Of the five included studies, practitioner impact was assessed in three. The five studies were generally at unclear risk of bias, and all evidence in the 'Summary of findings' table was graded by review authors as of very low quality. Meta-analysis of two studies revealed that a combination of several guideline dissemination and implementation strategies targeting healthcare professionals did not reduce antipsychotic co-prescribing in schizophrenia outpatients (two studies, n = 1,082, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.99 to 1.23; corrected for cluster design: n = 310, RR 0.97, CI 0.75 to 1.25). One trial, which studied a nurse-led intervention aimed at promoting cardiovascular disease screening, found a significant effect in terms of the proportion of people receiving screening (blood pressure: n = 96, RR 0.07, 95% CI 0.02 to 0.28; cholesterol: n = 103, RR 0.46, 95% CI 0.30 to 0.70; glucose: n = 103, RR 0.53, 95% CI 0.34 to 0.82; BMI: n = 99, RR 0.22, 95% CI 0.08 to 0.60; smoking status: n = 96, RR 0.28, 95% CI 0.12 to 0.64; Framingham score: n = 110, RR 0.69, 95% CI 0.55 to 0.87), although in the analysis corrected for cluster design, the effect was statistically significant for blood pressure and cholesterol only (blood pressure, corrected for cluster design: n = 33, RR 0.10, 95% CI 0.01 to 0.74; cholesterol, corrected for cluster design: n = 35, RR 0.49, 95% CI 0.24 to 0.99; glucose, corrected for cluster design: n = 35, RR 0.58, 95% CI 0.28 to 1.21; BMI, corrected for cluster design: n = 34, RR 0.18, 95% CI 0.02 to 1.37; smoking status, corrected for cluster design: n = 32, RR 0.25, 95% CI 0.06 to 1.03; Framingham score, corrected for cluster design: n = 38, RR 0.71, 95% CI 0.48 to 1.03; very low quality). Regarding participant outcomes, one trial assessed the efficacy of a shared decision-making implementation strategy and found no impact in terms of psychopathology, satisfaction with care and drug attitude. Another single trial studied a multifaceted intervention to promote medication adherence and found no impact in terms of adherence rates. With only five studies meeting inclusion criteria, and with limited low or very low quality usable information, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that, although small changes in psychiatric practice have been demonstrated, uncertainty remains in terms of clinically meaningful and sustainable effects of treatment guidelines on patient outcomes and how best to implement such guidelines for maximal benefit.

Identification of attributes that promote the adoption and implementation of 2005 Dietary Guidelines for Americans

USDA-ARS?s Scientific Manuscript database

As part of a larger study, this research was to identify attributes of the Dietary Guidelines for Americans (DGAs) that would promote their adoption and implementation by participants in a nutrition intervention. Project procedures were guided by the Diffusion of Innovations (DOI) theory. To identif...

Barriers to the implementation of practice guidelines in managing patients with nonvariceal upper gastrointestinal bleeding: A qualitative approach

PubMed Central

Hayes, Sean M; Murray, Suzanne; Dupuis, Martin; Dawes, Martin; Hawes, Ian A; Barkun, Alan N

2010-01-01

BACKGROUND/OBJECTIVE: Guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) are inconsistently applied by health care providers, potentially resulting in suboptimal care and patient outcomes. A needs assessment was performed to assess health care providers’ barriers to the implementation of these guidelines in Canada. METHODS: Semistructured telephone interviews were conducted by trained research personnel with 22 selectively sampled health care professionals actively treating and managing NVUGIB patients, including emergency room physicians (ER), intensivists (ICU), gastroenterologists (GI), gastroenterology nurses and hospital administrators. Participants were chosen from a representative sample of six Canadian community- and academic-based hospitals that participated in a national Canadian audit on the management of NVUGIB. RESULTS: Participants reported substantive gaps in the implementation of NVUGIB guidelines that included the following: lack of knowledge of the specifics of the NVUGIB guidelines (ER, ICU, nurses); limited belief in the value of guidelines, especially in areas where evidence is lacking (ER, ICU); limited belief in the value of available tools to support implementation of guidelines (GI); lack of knowledge of the roles and responsibilities of health care professions and disciplines, and lack of effective collaboration skills (ER, ICU and GI); variability of knowledge and skills of health care professionals within professions (eg, variability of nurses’ knowledge and skills in endoscopic procedures); and perceived overuse of intravenous proton pump inhibitor treatment, with limited concern regarding cost or side effect implications (all participants). CONCLUSIONS: In the present study population, ER, ICU and nurses did not adhere to NVUGIB guidelines because they were neither aware of nor familiar with them, whereas the GI lack of adherence to NVUGIB guidelines was influenced more by attitudinal and contextual barriers. These findings can guide the design of multifaceted educational and behavioural interventions when attempting to effectively disseminate existing guidelines, and for guideline implementation into practice. PMID:20485702

Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.

PubMed

Blumenthal, Kimberly G; Shenoy, Erica S; Varughese, Christy A; Hurwitz, Shelley; Hooper, David C; Banerji, Aleena

2015-10-01

Self-reported penicillin allergy infrequently reflects an inability to tolerate penicillins. Inpatients reporting penicillin allergy receive alternative antibiotics that might be broader spectrum, more toxic, or less effective. To develop and assess a clinical guideline for the general inpatient provider that directs taking a history and prescribing antibiotics for patients with penicillin or cephalosporin allergy. A guideline was implemented to assist providers with assessing allergy history and prescribing antibiotics for patients with reported penicillin or cephalosporin allergy. The guideline used a standard 2-step graded challenge or test dose. A quasi-experimental study was performed to assess safety, feasibility, and impact on antibiotic use by comparing treatment 21 months before guideline implementation with 12 months after guideline implementation. Significantly more test doses to β-lactam antibiotics were performed monthly after vs before guideline implementation (median 14.5, interquartile range 13-16.25, vs 2, interquartile range 1-3.25, P < .001). Seven adverse drug reactions occurred during guideline-driven test doses, with no significant difference in rate (3.9% vs 6.1%, P = .44) or severity (P > .5) between periods. Guideline-driven test doses decreased alternative antimicrobial therapy after the test dose, including vancomycin (68.3% vs 37.2%, P < .001), aztreonam (11.5% vs 0.5%, P < .001), aminoglycosides (6.0% vs 1.1%, P = .004), and fluoro quinolones (15.3% vs 3.3%, P < .001). The implementation of an inpatient antibiotic prescribing guideline for patients with penicillin or cephalosporin allergy was associated with an almost 7-fold increase in the number of test doses to β-lactams without increased adverse drug reactions. Patients assessed with guideline-driven test doses were observed to have significantly decreased alternative antibiotic exposure. Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

School nutrition guidelines: overview of the implementation and evaluation.

PubMed

Gregorič, Matej; Pograjc, Larisa; Pavlovec, Alenka; Simčič, Marjan; Gabrijelčič Blenkuš, Mojca

2015-06-01

To holistically evaluate the extent of implementation of dietary guidelines in schools and present various monitoring systems. The study comprises three methods: (i) a cross-sectional survey (process evaluation); (ii) an indicator-based evaluation (menu quality); and (iii) a 5 d weighed food record of school lunches (output evaluation). Slovenian primary schools. A total 234 food-service managers from 488 schools completed a self-administrated questionnaire for process evaluation; 177 out of 194 randomly selected schools provided menus for menu quality evaluation; and 120 school lunches from twenty-four schools were measured and nutritionally analysed for output evaluation. The survey among food-service managers revealed high levels of implementation at almost all process evaluation areas of the guidelines. An even more successful implementation of these guidelines was found in relation to organization cultural issues as compared with technical issues. Differences found in some process evaluation areas were related to location, size and socio-economic characteristics of schools. Evaluation of school menu quality demonstrated that score values followed a normal distribution. Higher (better) nutrition scores were found in larger-sized schools and corresponding municipalities with higher socio-economic status. School lunches did not meet minimum recommendations for energy, carbohydrates or dietary fibre intake, nor for six vitamins and three (macro, micro and trace) elements. The implementation of the guidelines was achieved differently at distinct levels. The presented multilevel evaluation suggests that different success in implementation might be attributed to different characteristics of individual schools. System changes might also be needed to support and improve implementation of the guidelines.

Clinical Practice Guidelines for Delirium Management: Potential Application in Palliative Care

PubMed Central

Bush, Shirley H.; Bruera, Eduardo; Lawlor, Peter G.; Kanji, Salmaan; Davis, Daniel H.J.; Agar, Meera; Wright, David; Hartwick, Michael; Currow, David C.; Gagnon, Bruno; Simon, Jessica; Pereira, José L.

2014-01-01

Context Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear. Objectives This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development. Methods We searched PubMed (1990–2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting. Results There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from “expert opinion” for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care. Conclusion Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development. PMID:24766743

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care.

PubMed

Kovacs, Eva; Strobl, Ralf; Phillips, Amanda; Stephan, Anna-Janina; Müller, Martin; Gensichen, Jochen; Grill, Eva

2018-05-04

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs). The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results. The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]). Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.

Implementation of the guidelines for targeted temperature management after cardiac arrest: a longitudinal qualitative study of barriers and facilitators perceived by hospital resuscitation champions.

PubMed

Kim, Young-Min; Lee, Seung Joon; Jo, Sun Jin; Park, Kyu Nam

2016-01-05

To identify the barriers to and facilitators of implementing guidelines for targeted temperature management (TTM) after cardiac arrest perceived by hospital resuscitation champions and to investigate the changes in their perceptions over the early implementation period. A longitudinal qualitative study (up to 2 serial semistructured interviews over 1 year and focus groups). The individual interviews and focus groups were transcribed and coded by 2 independent assessors. Contents were analysed thematically; group interaction was also examined. 21 hospitals, including community and tertiary care centres in South Korea. 21 hospital champions (14 acting champions and 7 managerial champions). The final data set included 40 interviews and 2 focus groups. The identified barriers and facilitators could be classified into 3 major themes: (1) healthcare professionals' perceptions of the guidelines and protocols, (2) interdisciplinary and interprofessional collaboration and (3) organisational resources. Lack of resources was the most commonly agreed on barrier for the acting champions, whereas lack of interdisciplinary collaboration was the most common barrier for the managerial champions. Educational activities and sharing successfully treated cases were the most frequently identified facilitators. Most of the participants identified and agreed that cooling equipment was an important barrier as well as a facilitator of successful TTM implementation. Perception of the guidelines and protocols has improved with the accumulation of clinical experience over the study period. Healthcare professionals' internal barriers to TTM implementation may be influenced by new guidelines and can be changed with the accumulation of successful clinical experiences during the early implementation period. Promoting interprofessional and interdisciplinary collaboration through educational activities and the use of cooling equipment with an automated feedback function can improve adherence to guidelines in hospitals with limited human resources in critical care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Implementation of the guidelines for targeted temperature management after cardiac arrest: a longitudinal qualitative study of barriers and facilitators perceived by hospital resuscitation champions

PubMed Central

Kim, Young-Min; Lee, Seung Joon; Jo, Sun Jin; Park, Kyu Nam

2016-01-01

Objectives To identify the barriers to and facilitators of implementing guidelines for targeted temperature management (TTM) after cardiac arrest perceived by hospital resuscitation champions and to investigate the changes in their perceptions over the early implementation period. Design A longitudinal qualitative study (up to 2 serial semistructured interviews over 1 year and focus groups). The individual interviews and focus groups were transcribed and coded by 2 independent assessors. Contents were analysed thematically; group interaction was also examined. Setting 21 hospitals, including community and tertiary care centres in South Korea. Participants 21 hospital champions (14 acting champions and 7 managerial champions). Results The final data set included 40 interviews and 2 focus groups. The identified barriers and facilitators could be classified into 3 major themes: (1) healthcare professionals’ perceptions of the guidelines and protocols, (2) interdisciplinary and interprofessional collaboration and (3) organisational resources. Lack of resources was the most commonly agreed on barrier for the acting champions, whereas lack of interdisciplinary collaboration was the most common barrier for the managerial champions. Educational activities and sharing successfully treated cases were the most frequently identified facilitators. Most of the participants identified and agreed that cooling equipment was an important barrier as well as a facilitator of successful TTM implementation. Perception of the guidelines and protocols has improved with the accumulation of clinical experience over the study period. Conclusions Healthcare professionals’ internal barriers to TTM implementation may be influenced by new guidelines and can be changed with the accumulation of successful clinical experiences during the early implementation period. Promoting interprofessional and interdisciplinary collaboration through educational activities and the use of cooling equipment with an automated feedback function can improve adherence to guidelines in hospitals with limited human resources in critical care. PMID:26733568

32 CFR 2004.11 - Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)].

Code of Federal Regulations, 2014 CFR

2014-07-01

..., or Guidelines [102(b)(3)]. 2004.11 Section 2004.11 National Defense Other Regulations Relating to... NATIONAL INDUSTRIAL SECURITY PROGRAM DIRECTIVE NO. 1 Implementation and Oversight § 2004.11 Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)]. (a) Reviews and Updates. All implementing...

32 CFR 2004.11 - Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)].

Code of Federal Regulations, 2012 CFR

2012-07-01

..., or Guidelines [102(b)(3)]. 2004.11 Section 2004.11 National Defense Other Regulations Relating to... NATIONAL INDUSTRIAL SECURITY PROGRAM DIRECTIVE NO. 1 Implementation and Oversight § 2004.11 Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)]. (a) Reviews and Updates. All implementing...

32 CFR 2004.11 - Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)].

Code of Federal Regulations, 2013 CFR

2013-07-01

..., or Guidelines [102(b)(3)]. 2004.11 Section 2004.11 National Defense Other Regulations Relating to... NATIONAL INDUSTRIAL SECURITY PROGRAM DIRECTIVE NO. 1 Implementation and Oversight § 2004.11 Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)]. (a) Reviews and Updates. All implementing...

32 CFR 2004.11 - Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)].

Code of Federal Regulations, 2011 CFR

2011-07-01

..., or Guidelines [102(b)(3)]. 2004.11 Section 2004.11 National Defense Other Regulations Relating to... NATIONAL INDUSTRIAL SECURITY PROGRAM DIRECTIVE NO. 1 Implementation and Oversight § 2004.11 Agency Implementing Regulations, Internal Rules, or Guidelines [102(b)(3)]. (a) Reviews and Updates. All implementing...

Implementation of GINA guidelines in Ho Chi Minh City: a model for Viet Nam.

PubMed

Tho, N V; Loan, H T H; Thao, N T P; Dung, N T T; Lan, L T T

2012-12-21

The Global Initiative for Asthma (GINA) guidelines have not been implemented effectively in primary care settings in Viet Nam. To estimate the proportion of patients with controlled asthma and the direct health care costs of managing asthma according to GINA guidelines at four out-patient clinics in Ho Chi Minh City (HCMC), Viet Nam. One hundred and six patients with asthma were treated and followed up according to GINA guidelines for 12 months. Clinical and pulmonary function responses and direct health care costs were evaluated every 3 months during the study. The proportion of patients with controlled asthma rose from 1.0% at the start of the study to 36.8% by the end of the study (P < 0.0001). The proportion of patients who had at least one hospitalisation per year decreased significantly, from 32.1% to 5.7% (P < 0.0001). The annual per patient median direct health care cost was US$169. Using asthma controllers continuously gave better asthma control than using them intermittently (OR 12.9, 95%CI 4.7-35.7). The implementation of GINA guidelines at out-patient clinics in HCMC, Viet Nam, improved asthma control with modest direct health care costs.

Using systems thinking to support clinical system transformation.

PubMed

Best, Allan; Berland, Alex; Herbert, Carol; Bitz, Jennifer; van Dijk, Marlies W; Krause, Christina; Cochrane, Douglas; Noel, Kevin; Marsden, Julian; McKeown, Shari; Millar, John

2016-05-16

Purpose - The British Columbia Ministry of Health's Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC's health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings. Design/methodology/approach - Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey. Findings - The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system. Research limitations/implications - The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels - policy, management and practice - about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue. Practical implications - Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues. Originality/value - Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

Reversing the pipeline? Implementing public health evidence-based guidance in english local government.

PubMed

Atkins, Lou; Kelly, Michael P; Littleford, Clare; Leng, Gillian; Michie, Susan

2017-05-12

In the UK, responsibility for many public health functions was transferred in 2013 from the National Health Service (NHS) to local government; a very different political context and one without the NHS history of policy and practice being informed by evidence-based guidelines. A problem this move presented was whether evidence-based guidelines would be seen as relevant, useful and implementable within local government. This study investigates three aspects of implementing national evidence-based recommendations for public health within a local government context: influences on implementation, how useful guidelines are perceived to be and whether the linear evidence-guidelines-practice model is considered relevant. Thirty-one councillors, public health directors and deputy directors and officers and other local government employees were interviewed about their experiences implementing evidence-based guidelines. Interviews were informed and analysed using a theoretical model of behaviour (COM-B; Capability, Opportunity, Motivation-Behaviour). Contextual issues such as budget, capacity and political influence were important influences on implementation. Guidelines were perceived to be of limited use, with concerns expressed about recommendations being presented in the abstract, lacking specificity and not addressing the complexity of situations or local variations. Local evidence was seen as the best starting point, rather than evidence-based guidance produced by the traditional linear 'evidence-guidelines-practice' model. Local evidence was used to not only provide context for recommendations but also replace recommendations when they conflicted with local evidence. Local government users do not necessarily consider national guidelines to be fit for purpose at local level, with the consequence that local evidence tends to trump evidence-based guidelines. There is thus a tension between the traditional model of guideline development and the needs of public health decision-makers and practitioners working in local government. This tension needs to be addressed to facilitate implementation. One way this might be achieved, and participants supported this approach, would be to reverse or re-engineer the traditional pipeline of guideline development by starting with local need and examples of effective local practice rather than starting with evidence of effectiveness synthesised from the international scientific literature. Alternatively, and perhaps in addition, training about the relevance of research evidence should become a routine for local government staff and councillors.

Implementation of pregnancy weight management and obesity guidelines: a meta-synthesis of healthcare professionals' barriers and facilitators using the Theoretical Domains Framework.

PubMed

Heslehurst, N; Newham, J; Maniatopoulos, G; Fleetwood, C; Robalino, S; Rankin, J

2014-06-01

Obesity in pregnancy is rising and is associated with severe health consequences for both the mother and the child. There is an increasing international focus on guidelines to manage the clinical risks of maternal obesity, and for pregnancy weight management. However, passive dissemination of guidelines is not effective and more active strategies are required for effective guideline implementation into practice. Implementation of guidelines is a form of healthcare professional behaviour change, and therefore implementation strategies should be based on appropriate behaviour change theory. This systematic review aimed to identify the determinants of healthcare professionals' behaviours in relation to maternal obesity and weight management. Twenty-five studies were included. Data synthesis of the existing international qualitative and quantitative evidence base used the Theoretical Domains Framework to identify the barriers and facilitators to healthcare professionals' maternal obesity and weight management practice. The domains most frequently identified included 'knowledge', 'beliefs about consequences' and 'environmental context and resources'. Healthcare professionals' weight management practice had the most barriers compared with any other area of maternal obesity practice. The results of this review will be used to inform the development of an intervention to support healthcare professional behaviour change. © 2014 The Authors. obesity reviews © 2014 International Association for the Study of Obesity.

The ASM Curriculum Guidelines for Undergraduate Microbiology: A Case Study of the Advocacy Role of Societies in Reform Efforts

PubMed Central

Horak, Rachel E. A.; Merkel, Susan; Chang, Amy

2015-01-01

A number of national reports, including Vision and Change in Undergraduate Biology Education: A Call to Action, have called for drastic changes in how undergraduate biology is taught. To that end, the American Society for Microbiology (ASM) has developed new Curriculum Guidelines for undergraduate microbiology that outline a comprehensive curriculum for any undergraduate introductory microbiology course or program of study. Designed to foster enduring understanding of core microbiology concepts, the Guidelines work synergistically with backwards course design to focus teaching on student-centered goals and priorities. In order to qualitatively assess how the ASM Curriculum Guidelines are used by educators and learn more about the needs of microbiology educators, the ASM Education Board distributed two surveys to the ASM education community. In this report, we discuss the results of these surveys (353 responses). We found that the ASM Curriculum Guidelines are being implemented in many different types of courses at all undergraduate levels. Educators indicated that the ASM Curriculum Guidelines were very helpful when planning courses and assessments. We discuss some specific ways in which the ASM Curriculum Guidelines have been used in undergraduate classrooms. The survey identified some barriers that microbiology educators faced when trying to adopt the ASM Curriculum Guidelines, including lack of time, lack of financial resources, and lack of supporting resources. Given the self-reported challenges to implementing the ASM Curriculum Guidelines in undergraduate classrooms, we identify here some activities related to the ASM Curriculum Guidelines that the ASM Education Board has initiated to assist educators in the implementation process. PMID:25949769

The ASM Curriculum Guidelines for Undergraduate Microbiology: A Case Study of the Advocacy Role of Societies in Reform Efforts.

PubMed

Horak, Rachel E A; Merkel, Susan; Chang, Amy

2015-05-01

A number of national reports, including Vision and Change in Undergraduate Biology Education: A Call to Action, have called for drastic changes in how undergraduate biology is taught. To that end, the American Society for Microbiology (ASM) has developed new Curriculum Guidelines for undergraduate microbiology that outline a comprehensive curriculum for any undergraduate introductory microbiology course or program of study. Designed to foster enduring understanding of core microbiology concepts, the Guidelines work synergistically with backwards course design to focus teaching on student-centered goals and priorities. In order to qualitatively assess how the ASM Curriculum Guidelines are used by educators and learn more about the needs of microbiology educators, the ASM Education Board distributed two surveys to the ASM education community. In this report, we discuss the results of these surveys (353 responses). We found that the ASM Curriculum Guidelines are being implemented in many different types of courses at all undergraduate levels. Educators indicated that the ASM Curriculum Guidelines were very helpful when planning courses and assessments. We discuss some specific ways in which the ASM Curriculum Guidelines have been used in undergraduate classrooms. The survey identified some barriers that microbiology educators faced when trying to adopt the ASM Curriculum Guidelines, including lack of time, lack of financial resources, and lack of supporting resources. Given the self-reported challenges to implementing the ASM Curriculum Guidelines in undergraduate classrooms, we identify here some activities related to the ASM Curriculum Guidelines that the ASM Education Board has initiated to assist educators in the implementation process.

[Evidence-based clinical oral healthcare guidelines 4. Adherence requires an implementation strategy].

PubMed

Braspenning, J C C; Mettes, T G P H; van der Sanden, W J M; Wensing, M J P

2015-03-01

Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.

Barriers and Enablers to Implementation of Dietary Guidelines in Early Childhood Education Centers in Australia: Application of the Theoretical Domains Framework.

PubMed

Grady, Alice; Seward, Kirsty; Finch, Meghan; Fielding, Alison; Stacey, Fiona; Jones, Jannah; Wolfenden, Luke; Yoong, Sze Lin

2018-03-01

To identify perceived barriers and enablers to implementation of dietary guidelines reported by early childhood education center cooks, and barriers and enablers associated with greater implementation based on assessment of center menu compliance. Cross-sectional telephone interview. Early childhood education centers, New South Wales, Australia. A total of 202 cooks responsible for menu planning; 70 centers provided a menu for review of compliance with dietary guidelines. Barriers and enablers to dietary guideline implementation were determined using a tool assessing constructs of the Theoretical Domains Framework (TDF). Higher scores (≥6) for each construct indicated enablers to guideline implementation; lower scores (<6) suggested barriers. Multivariable linear regression identified TDF constructs associated with greater guideline implementation. Scores were lowest for reinforcement (mean, 5.85) and goals (mean, 5.89) domains, and highest for beliefs about consequences (mean, 6.51) and social/professional role and identity (mean, 6.50). The skills domain was positively associated with greater implementation of guidelines based on menu review (P = .01). Cooks perceived social/professional role and identity, and beliefs about consequences to be enablers to dietary guideline implementation; however, only the skills domain was associated with greater implementation. There are opportunities to target the incongruence in perceptions vs reality of the barriers and enablers to implementation. Future research could examine the utility of the TDF to identify barriers and enablers to implementation to inform intervention development and for evaluating interventions to examine intervention mechanisms. Copyright © 2017 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

Translating New Lung Cancer Screening Guidelines into Practice: The Experience of One Community Hospital.

PubMed

Ledford, Christy J W; Gawrys, Breanna L; Wall, Jessica L; Saas, Patrick D; Seehusen, Dean A

2016-01-01

In December 2013 the US Preventive Services Task Force issued a recommendation for lung cancer screening with annual low-dose computed tomography (LDCT). As screening guidelines emerge and change, this creates an environment for studying the translation of these guidelines into practice. This study assessed how these guidelines were implemented in a community hospital setting and the resulting radiologic findings. This observational study examined the radiologic outcomes of LDCT lung cancer screening guidelines and the resulting notification. During the first year after publication of the guidelines, 94 screening LDCT scans were ordered. Of these, 21 (22.3%) did not meet the criteria outlined by the US Preventive Services Task Force. Among the 72 cases that did met published criteria, 65.3% of scans detected nodules, and among the remaining 35.6%, half had another clinically significant finding. This study shows that new lung cancer screening guidelines, as implemented at a community hospital, resulted in radiologic findings that required follow-up in more than half of patients. Clinicians must be aware of these potential incidental findings when talking to patients about the decision to order screenings. © Copyright 2016 by the American Board of Family Medicine.

Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit.

PubMed

Kyle, Ursula G; Lucas, Laura A; Mackey, Guisela; Silva, Jaime C; Lusk, Jennifer; Orellana, Renan; Shekerdemian, Lara S; Coss-Bu, Jorge A

2016-05-01

Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality. The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU). This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively. Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation). Implementation of NS Guidelines. Changes in actual energy and protein intake in the post- compared with the pre-Implementation period. Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score. After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively. The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children. Copyright © 2016 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Bridging the Guideline Implementation Gap: A Systematic, Document-Centered Approach to Guideline Implementation

PubMed Central

Shiffman, Richard N.; Michel, George; Essaihi, Abdelwaheb; Thornquist, Elizabeth

2004-01-01

Objective: A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. Design: This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. Results: The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. Conclusion: Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge. PMID:15187061

Canadian 24-Hour Movement Guidelines for Children and Youth: Exploring the perceptions of stakeholders regarding their acceptability, barriers to uptake, and dissemination.

PubMed

Faulkner, Guy; White, Lauren; Riazi, Negin; Latimer-Cheung, Amy E; Tremblay, Mark S

2016-06-01

Engaging stakeholders in the development of guidelines and plans for implementation is vital. The purpose of this study was to examine stakeholders' (parents, teachers, exercise professionals, paediatricians, and youth) perceptions of the Canadian 24-Hour Movement Behaviour Guidelines for Children and Youth ("Movement Guidelines"). Stakeholders (n = 104) engaged in semi-structured focus groups or interviews to discuss the perceived acceptability of the guidelines, potential barriers to implementation, and preferred methods and messengers of dissemination. A thematic analysis was conducted. Overall, there was consistent support across all stakeholder groups, with the exception of youth participants, for the Movement Guidelines. Stakeholders identified a range of barriers to the uptake of the guidelines including concerns with accurately defining key terms such as "recreational" screen time; everyday challenges such as financial and time constraints; and the possibility of the Movement Guidelines becoming just another source of stress and guilt for already busy and overwhelmed parents. Participants identified a range of recommended methods and messengers for future dissemination. School and medical settings were the most commonly recommended settings through which dissemination efforts should be delivered. Overall, participants representing a range of stakeholder groups were receptive to the new Movement Guidelines and endorsed their value. In complementing the Movement Guidelines, messaging and resources will need to be developed that address common concerns participants had regarding their dissemination and implementation.

The Identification, Implementation, and Evaluation of Critical User Interface Design Features of Computer-Assisted Instruction Programs in Mathematics for Students with Learning Disabilities

ERIC Educational Resources Information Center

Seo, You-Jin; Woo, Honguk

2010-01-01

Critical user interface design features of computer-assisted instruction programs in mathematics for students with learning disabilities and corresponding implementation guidelines were identified in this study. Based on the identified features and guidelines, a multimedia computer-assisted instruction program, "Math Explorer", which delivers…

Dissemination Strategies to Improve Implementation of the PHS Smoking Cessation Guideline in MCH Public Health Clinics: Experimental Evaluation Results and Contextual Factors

ERIC Educational Resources Information Center

Manfredi, Clara; Cho, Young Ik; Warnecke, Richard; Saunders, Stephen; Sullivan, Myrtis

2011-01-01

We report results from an experimental study that tested the effectiveness of dissemination interventions to improve implementation of smoking cessation guidelines in maternal and child public health clinics. We additionally examine individual clinic results for contextual explanations not apparent from the experimental findings alone. Twelve…

Implementation of Spanish adaptation of the European guidelines on cardiovascular disease prevention in primary care

PubMed Central

2013-01-01

Background The successful implementation of cardiovascular disease (CVD) prevention guidelines relies heavily on primary care physicians (PCPs) providing risk factor evaluation, intervention and patient education. The aim of this study was to ascertain the degree of awareness and implementation of the Spanish adaptation of the European guidelines on CVD prevention in clinical practice (CEIPC guidelines) among PCPs. Methods A cross-sectional survey of PCPs was conducted in Spain between January and June 2011. A random sample of 1,390 PCPs was obtained and stratified by region. Data were collected by means of a self-administered questionnaire. Results More than half (58%) the physicians were aware of and knew the recommendations, and 62% of those claimed to use them in clinical practice, with general physicians (without any specialist accreditation) being less likely to so than family doctors. Most PCPs (60%) did not assess cardiovascular risk, with the limited time available in the surgery being cited as the greatest barrier by 81%. The main reason to be sceptical about recommendations, reported by 71% of physicians, was that there are too many guidelines. Almost half the doctors cited the lack of training and skills as the greatest barrier to the implementation of lifestyle and behavioural change recommendations. Conclusions Most PCPs were aware of the Spanish adaptation of the European guidelines on CVD prevention (CEIPC guidelines) and knew their content. However, only one third of PCPs used the guidelines in clinical practice and less than half CVD risk assessment tools. PMID:23506390

A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: a novel implementation strategy for adopting clinical guidelines for Opioid prescribing in primary care.

PubMed

Quanbeck, Andrew; Brown, Randall T; Zgierska, Aleksandra E; Jacobson, Nora; Robinson, James M; Johnson, Roberta A; Deyo, Brienna M; Madden, Lynn; Tuan, Wen-Jan; Alagoz, Esra

2018-01-25

This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named "systems consultation" aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels. We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques. Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: "I am more familiar with guidelines for safe opioid prescribing" and "My clinic's workflow for opioid prescribing is easier." At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes. The systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare. ClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496 Registered May 5, 2015.

Advancing Evidence-Based Practice in Physical Therapy Settings: Multinational Perspectives on Implementation Strategies and Interventions.

PubMed

Bernhardsson, Susanne; Lynch, Elizabeth; Dizon, Janine Margarita; Fernandes, Jasmin; Gonzalez-Suarez, Consuelo; Lizarondo, Lucylynn; Luker, Julie; Wiles, Louise; Grimmer, Karen

2017-01-01

It is of critical importance that findings from the wealth of clinical physical therapist research are transferred into clinical practice without unnecessary delays. There is a lack of knowledge about strategies that can be used to effectively implement physical therapist research findings and evidence-based practice (EBP) into everyday clinical practice in different national settings and contexts. The purpose of this article is to contribute to knowledge about effective strategies for implementing EBP that have been studied in different national physical therapy settings. The specific aims of this article are to share experiences and provide a current multinational perspective on different approaches and strategies for implementing EBP and to highlight important considerations and implications for both research and practice. Six research studies from various settings in 3 countries are described and synthesized. Key characteristics of the studies and intervention components are tabulated and mapped to the Cochrane Effective Practice and Organisation of Care taxonomy. Commonalities and differences are presented. The implementation strategies described were: a theory-based guideline implementation tailored to identified barriers and facilitators; a multifaceted EBP training package; journal clubs; a multifaceted strategy comprising contextualized procedures, protocols, and standardized resources; barrier identification, education, audit, feedback, and reminders; and contextualized guidelines. Commonalities were the use of a multifaceted approach, educational measures, and clinical guidelines. Key outcomes across the studies were improved attitudes and increased awareness, knowledge, skills, and confidence in EBP; better access to clinical practice guidelines and other EBP resources; identification of barriers that could be targeted in future implementation activities; earlier referrals; and use of recommended outcome measures. The article can serve as a template for other physical therapist researchers in designing implementation studies, as well as to inform policies and practice for health care managers and decision makers who are looking for ways to implement research findings in their organizations. © 2017 American Physical Therapy Association.

Barriers and Strategies in Guideline Implementation—A Scoping Review

PubMed Central

Fischer, Florian; Lange, Kerstin; Klose, Kristina; Greiner, Wolfgang; Kraemer, Alexander

2016-01-01

Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed. PMID:27417624

The Pathways study: a model for lowering the fat in school meals

PubMed Central

Snyder, Patricia; Anliker, Jean; Cunningham-Sabo, Leslie; Dixon, Lori Beth; Altaha, Jackie; Chamberlain, Arlene; Davis, Sally; Evans, Marguerite; Hurley, Joanne; Weber, Judith L

2016-01-01

We describe the development and implementation of the Pathways school food service intervention during the feasibility phase of the Pathways study. The purpose of the intervention was to lower the amount of fat in school meals to 30% of energy to promote obesity prevention in third- through fifth-grade students. The Pathways nutrition staff and the food service intervention staff worked together to develop 5 interrelated components to implement the intervention. These components were nutrient guidelines, 8 skill-building behavioral guidelines, hands-on materials, twice yearly trainings, and monthly visits to the kitchens by the Pathways nutrition staff. The components were developed and implemented over 18 mo in a pilot intervention in 4 schools. The results of an initial process evaluation showed that 3 of the 4 schools had implemented 6 of the 8 behavioral guidelines. In an analysis of 5 d of school menus from 3 control schools, the lunch menus averaged from 34% to 40% of energy from fat; when the menus were analyzed by using the food preparation and serving methods in the behavioral guidelines, they averaged 31% of energy from total fat. This unique approach of 5 interrelated food service intervention components was accepted in the schools and is now being implemented in the full-scale phase of the Pathways study in 40 schools for 5 y. PMID:10195607

Implementation of national comprehensive cancer network evidence-based guidelines to prevent and treat cancer-related infections.

PubMed

Wood, Sylvia K; Payne, Judith K

2012-06-01

Clinical practice guidelines are an important result of evidence-based research. However, current clinical practice remains out of step with the rapid pace of research advancements. Often, decades pass before research is translated into clinical practice. The National Comprehensive Cancer Network (NCCN) has created evidence-based clinical guidelines to promote effective clinical practice. Formerly, the NCCN established guidelines to reduce cancer-related infections only for neutropenic patients; however, they have expanded their guidelines beyond neutropenia to prevent and treat cancer-related infections. Implementing scientific evidence into clinical practice is challenging and complex, and healthcare professionals should understand barriers to implementing clinical practice guidelines to ensure successful translation into practice. This article provides a brief review of NCCN guidelines and describes common barriers encountered during implementation. In addition, a conceptual framework is offered to help identify and address potential concerns before and after adoption of guidelines.

Guidelines and mHealth to Improve Quality of Hypertension and Type 2 Diabetes Care for Vulnerable Populations in Lebanon: Longitudinal Cohort Study

PubMed Central

Paik, Kenneth E; Hei Tam, Hok; Fahed, Zeina; Winkler, Eric; Kontunen, Kaisa; Mkanna, Abdalla; Burnham, Gilbert

2017-01-01

Background Given the protracted nature of the crisis in Syria, the large noncommunicable disease (NCD) caseload of Syrian refugees and host Lebanese, and the high costs of providing NCD care, the implications for Lebanon’s health system are vast. Objective The aim of this study was to evaluate the effectiveness of treatment guidelines and a mobile health (mHealth) app on quality of care and health outcomes in primary care settings in Lebanon. Methods A longitudinal cohort study was implemented from January 2015 to August 2016 to evaluate the effectiveness of treatment guidelines and an mHealth app on quality of care and health outcomes for Syrian and Lebanese patients in Lebanese primary health care (PHC) facilities. Results Compared with baseline record extraction, recording of blood pressure (BP) readings (−11.4%, P<.001) and blood sugar measurements (−6.9%, P=.03) significantly decreased following the implementation of treatment guidelines. Recording of BP readings also decreased after the mHealth phase as compared with baseline (−8.4%, P=.001); however, recording of body mass index (BMI) reporting increased at the end of the mHealth phase from baseline (8.1%, P<.001) and the guidelines phase (7.7%, P<.001). There were a great proportion of patients for whom blood sugar, BP, weight, height, and BMI were recorded using the tablet compared with in paper records; however, only differences in BMI were statistically significant (31.6% higher in app data as compared with paper records; P<.001). Data extracted from the mHealth app showed that a higher proportion of providers offered lifestyle counseling compared with the counseling reported in patients’ paper records (health diet counseling; 77.3% in app data vs 8.8% in paper records, P<.001 and physical activity counseling and 59.7% in app vs 7.1% in paper records, P<.001). There were statistically significant increases in all four measures of patient-provider interaction across study phases. Provider inquiry of medical history increased by 16.6% from baseline following guideline implementation and by 28.2% from baseline to mHealth implementation (P<.001). From baseline, patient report of provider inquiry regarding medication complications increased in the guidelines and mHealth phases by 12.9% and 59.6%, respectively, (P<.001). The proportion of patients reporting that providers asked other questions relevant to their illness increased from baseline through guidelines implementation by 27.8% and to mHealth implementation by 66.3% (P<.001). Follow-up scheduling increased from baseline to the guidelines phase by 20.6% and the mHealth phase by 39.8% (P<.001). Conclusions Results from this study of an mHealth app in 10 PHC facilities in Lebanon indicate that the app has potential to improve adherence to guidelines and quality of care. Further studies are necessary to determine the effects of patient-controlled health record apps on provider adherence to treatment guidelines, as well as patients’ long-term medication and treatment adherence and disease control. PMID:29046266

Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.

PubMed

Lind, S; Wallin, L; Brytting, T; Fürst, C J; Sandberg, J

2017-11-01

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care. Copyright © 2017 Elsevier B.V. All rights reserved.

Physicians' preferences for asthma guidelines implementation.

PubMed

Kang, Min-Koo; Kim, Byung-Keun; Kim, Tae-Wan; Kim, Sae-Hoon; Kang, Hye-Ryun; Park, Heung-Woo; Chang, Yoon-Seok; Kim, Sun-Sin; Min, Kyung-Up; Kim, You-Young; Cho, Sang-Heon

2010-10-01

Patient care based on asthma guidelines is cost-effective and leads to improved treatment outcomes. However, ineffective implementation strategies interfere with the use of these recommendations in clinical practice. This study investigated physicians' preferences for asthma guidelines, including content, supporting evidence, learning strategies, format, and placement in the clinical workplace. We obtained information through a questionnaire survey. The questionnaire was distributed to physicians attending continuing medical education courses and sent to other physicians by airmail, e-mail, and facsimile. A total of 183 physicians responded (male to female ratio, 2.3:1; mean age, 40.4±9.9 years); 89.9% of respondents were internists or pediatricians, and 51.7% were primary care physicians. Physicians preferred information that described asthma medications, classified the disease according to severity and level of control, and provided methods of evaluation/treatment/monitoring and management of acute exacerbation. The most effective strategies for encouraging the use of the guidelines were through continuing medical education and discussions with colleagues. Physicians required supporting evidence in the form of randomized controlled trials and expert consensus. They preferred that the guidelines be presented as algorithms or flow charts/flow diagrams on plastic sheets, pocket cards, or in electronic medical records. This study identified the items of the asthma guidelines preferred by physicians in Korea. Asthma guidelines with physicians' preferences would encourage their implementation in clinical practice.

Developing and Implementing Health and Sustainability Guidelines for Institutional Food Service123

PubMed Central

Kimmons, Joel; Jones, Sonya; McPeak, Holly H.; Bowden, Brian

2012-01-01

Health and sustainability guidelines for institutional food service are directed at improving dietary intake and increasing the ecological benefits of the food system. The development and implementation of institutional food service guidelines, such as the Health and Human Services (HHS) and General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines), have the potential to improve the health and sustainability of the food system. Institutional guidelines assist staff, managers, and vendors in aligning the food environment at food service venues with healthier and more sustainable choices and practices. Guideline specifics and their effective implementation depend on the size, culture, nature, and management structure of an institution and the individuals affected. They may be applied anywhere food is sold, served, or consumed. Changing institutional food service practice requires comprehensive analysis, engagement, and education of all relevant stakeholders including institutional management, members of the food supply chain, and customers. Current examples of food service guidelines presented here are the HHS and GSA Health and Sustainability Guidelines for Federal Concessions and Vending Operations, which translate evidence-based recommendations on health and sustainability into institutional food service practices and are currently being implemented at the federal level. Developing and implementing guidelines has the potential to improve long-term population health outcomes while simultaneously benefitting the food system. Nutritionists, public health practitioners, and researchers should consider working with institutions to develop, implement, and evaluate food service guidelines for health and sustainability. PMID:22585909

Developing and implementing health and sustainability guidelines for institutional food service.

PubMed

Kimmons, Joel; Jones, Sonya; McPeak, Holly H; Bowden, Brian

2012-05-01

Health and sustainability guidelines for institutional food service are directed at improving dietary intake and increasing the ecological benefits of the food system. The development and implementation of institutional food service guidelines, such as the Health and Human Services (HHS) and General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines), have the potential to improve the health and sustainability of the food system. Institutional guidelines assist staff, managers, and vendors in aligning the food environment at food service venues with healthier and more sustainable choices and practices. Guideline specifics and their effective implementation depend on the size, culture, nature, and management structure of an institution and the individuals affected. They may be applied anywhere food is sold, served, or consumed. Changing institutional food service practice requires comprehensive analysis, engagement, and education of all relevant stakeholders including institutional management, members of the food supply chain, and customers. Current examples of food service guidelines presented here are the HHS and GSA Health and Sustainability Guidelines for Federal Concessions and Vending Operations, which translate evidence-based recommendations on health and sustainability into institutional food service practices and are currently being implemented at the federal level. Developing and implementing guidelines has the potential to improve long-term population health outcomes while simultaneously benefitting the food system. Nutritionists, public health practitioners, and researchers should consider working with institutions to develop, implement, and evaluate food service guidelines for health and sustainability.

Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial.

PubMed

Suman, Arnela; Schaafsma, Frederieke G; Elders, Petra J M; van Tulder, Maurits W; Anema, Johannes R

2015-05-31

Low back pain (LBP) is one of the most prevalent and expensive health care problems in industrialised countries. LBP leads to high health care utility and productivity losses; leaving the individual, the employer, and society with substantial costs. To improve the care for LBP patients and reduce the high societal and financial burden of LBP, in 2010 the 'Multidisciplinary care guideline for nonspecific low back pain' was developed in the Netherlands. The current paper describes the design of a study aiming to evaluate the (cost-) effectiveness of a multifaceted strategy to implement this guideline. In a cluster-randomised controlled trial, the (cost-) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination. Using a stepped-wedge approach, participating general practitioners, physiotherapists, and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session. The timing these clusters receive the training is the unit of randomisation. LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aimed at improving beliefs, cognitions, and self-management. The primary outcome measure of this study is patient back beliefs. Secondary outcome measures on patient level include pain, functional status, quality of life, health care utility, and productivity losses. Outcome measures on professional level include knowledge and attitude towards the guideline, and guideline adherence. A process evaluation for the implementation strategy will be performed among the health care providers and the patients. Furthermore, a qualitative subgroup analysis among patients with various ethnic backgrounds will be performed. This study will give insight into the (cost-) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level. The valuable information gained with this study may prove useful for policy-makers, health care providers, and researchers who are in the process of reducing the burden of back pain on individuals and society. Netherlands Trial Register (NTR): NTR4329. Registered December 20th, 2013.

Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care?

PubMed

Breen, Alan C; van Tulder, Maurits W; Koes, Bart W; Jensen, Irene; Reardon, Rhoda; Bronfort, Gert

2006-05-01

Description of a workshop entitled "Sharing Guidelines for Low Back Pain Between Primary Health Care Providers: Toward a Common Message in Primary Care" that was held at the Fifth International Forum on Low Back Pain in Primary Care in Canada in May 2002. Despite a considerable degree of acceptance of current evidence-based guidelines, in practice, primary health care providers still do not share a common message. The objective of the workshop was to describe the outcomes of a workshop on the sharing of guidelines in primary care. The Fifth International Forum on Low Back Pain Research in Primary Care focused on relations between stakeholders in the primary care management of back pain. Participants in this workshop contributed to an open discussion on "how and why" evidence-based guidelines about back pain do or do not work in practice. Ways to minimise the factors that inhibit implementation were discussed in the light of whether guidelines are mono-disciplinary or multidisciplinary. Examples of potential issues for debate were contained in introductory presentations. The prospects for improving implementation and reducing barriers, and the priorities for future research, were then considered by an international group of researchers. This paper summarises the conclusions of three researcher subgroups that focused on the sharing of guidelines under the headings of: (1) the content, (2) the development process, and (3) implementation. How to share the evidence and make it meaningful to practice stakeholders is the main challenge of guideline implementation. There is a need to consider the balance between the strength of evidence in multidisciplinary guidelines and the utility/feasibility of mono-disciplinary guidelines. The usefulness of both mono-disciplinary and multidisciplinary guidelines was agreed on. However, in order to achieve consistent messages, mono-disciplinary guidelines should have a multidisciplinary parent. In other words, guidelines should be developed and monitored by a multidisciplinary team, but may be transferred to practice by mono-disciplinary messengers. Despite general agreement that multi-faceted interventions are most effective for implementing guidelines, the feasibility of doing this in busy clinical settings is questioned. Research is needed from local implementation pilots and quality monitoring studies to understand how to develop and deliver the contextual understanding required. This relates to processes of care as well as outcomes, and to social factors and policymaking as well as health care interventions. We commend these considerations to all who are interested in the challenges of achieving better-integrated, evidence-based care for people with back pain.

Clinical practice guidelines for delirium management: potential application in palliative care.

PubMed

Bush, Shirley H; Bruera, Eduardo; Lawlor, Peter G; Kanji, Salmaan; Davis, Daniel H J; Agar, Meera; Wright, David Kenneth; Hartwick, Michael; Currow, David C; Gagnon, Bruno; Simon, Jessica; Pereira, José L

2014-08-01

Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear. This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development. We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting. There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care. Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

48 CFR 47.403 - Guidelines for implementation of the Fly America Act.

Code of Federal Regulations, 2014 CFR

2014-10-01

... implementation of the Fly America Act. 47.403 Section 47.403 Federal Acquisition Regulations System FEDERAL... Guidelines for implementation of the Fly America Act. This section 47.403 is based on the Guidelines for Implementation of the Fly America Act (case number B-138942), issued by the Comptroller General of the United...

48 CFR 47.403 - Guidelines for implementation of the Fly America Act.

Code of Federal Regulations, 2011 CFR

2011-10-01

... implementation of the Fly America Act. 47.403 Section 47.403 Federal Acquisition Regulations System FEDERAL... Guidelines for implementation of the Fly America Act. This section 47.403 is based on the Guidelines for Implementation of the Fly America Act (case number B-138942), issued by the Comptroller General of the United...

48 CFR 47.403 - Guidelines for implementation of the Fly America Act.

Code of Federal Regulations, 2012 CFR

2012-10-01

... implementation of the Fly America Act. 47.403 Section 47.403 Federal Acquisition Regulations System FEDERAL... Guidelines for implementation of the Fly America Act. This section 47.403 is based on the Guidelines for Implementation of the Fly America Act (case number B-138942), issued by the Comptroller General of the United...

48 CFR 47.403 - Guidelines for implementation of the Fly America Act.

Code of Federal Regulations, 2013 CFR

2013-10-01

... implementation of the Fly America Act. 47.403 Section 47.403 Federal Acquisition Regulations System FEDERAL... Guidelines for implementation of the Fly America Act. This section 47.403 is based on the Guidelines for Implementation of the Fly America Act (case number B-138942), issued by the Comptroller General of the United...

Improving the implementation of perioperative safety guidelines using a multifaceted intervention approach: protocol of the IMPROVE study, a stepped wedge cluster randomized trial.

PubMed

Emond, Yvette E J J M; Calsbeek, Hiske; Teerenstra, Steven; Bloo, Gerrit J A; Westert, Gert P; Damen, Johan; Wolff, André P; Wollersheim, Hub C

2015-01-08

This study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed. This is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is conducted to identify the compliance with the implementation strategy, as well as an economic evaluation to assess the costs. Data sources are registered clinical data and surveys. There is no form of blinding. The perioperative setting is an unexplored area with respect to implementation issues. This study is expected to yield important new evidence about the effects of a multifaceted approach on guideline adherence in the perioperative care setting. Dutch trial registry: NTR3568.

Applying openEHR's Guideline Definition Language to the SITS international stroke treatment registry: a European retrospective observational study.

PubMed

Anani, Nadim; Mazya, Michael V; Chen, Rong; Prazeres Moreira, Tiago; Bill, Olivier; Ahmed, Niaz; Wahlgren, Nils; Koch, Sabine

2017-01-10

Interoperability standards intend to standardise health information, clinical practice guidelines intend to standardise care procedures, and patient data registries are vital for monitoring quality of care and for clinical research. This study combines all three: it uses interoperability specifications to model guideline knowledge and applies the result to registry data. We applied the openEHR Guideline Definition Language (GDL) to data from 18,400 European patients in the Safe Implementation of Treatments in Stroke (SITS) registry to retrospectively check their compliance with European recommendations for acute stroke treatment. Comparing compliance rates obtained with GDL to those obtained by conventional statistical data analysis yielded a complete match, suggesting that GDL technology is reliable for guideline compliance checking. The successful application of a standard guideline formalism to a large patient registry dataset is an important step toward widespread implementation of computer-interpretable guidelines in clinical practice and registry-based research. Application of the methodology gave important results on the evolution of stroke care in Europe, important both for quality of care monitoring and clinical research.

PP167. A process evaluation of an innovative implementation strategy of the Dutch guidelines on hypertensive disorders in pregnancy using a computerized decision support system.

PubMed

Luitjes, S; Mesri, K; Wouters, M; van Tulder, M; Hermens, R

2012-07-01

Hypertensive disorders in pregnancy remain the leading cause of maternal mortality in the Netherlands. The Dutch Society of Obstetrics and Gynecology (NVOG) has developed evidence-based guidelines on the management of hypertension in pregnancy. Previous studies showed a low adherence rate to other NVOG guidelines and a large variation in usual care in different hospitals. In the BIG CHANGE trial an innovative implementation strategy of the NVOG guidelines on hypertension using a web-based application (BOS, by Giant Soft, Leeuwarden, The Netherlands) was compared to a common strategy of professional audit and feedback. In this study a process evaluation of BOS has been done, analyzing its efficiency, barriers and formulate improvement points. Gynecologists, residents and clinical midwives from seven hospitals using BOS were asked to fill in the questionnaire. A questionnaire was developed on the following items: efficiency, barriers and improvement. Thirty four completed questionnaires useful for analysis. 63.6% of the respondent also consulted the NVOG guideline or local protocol, mainly for confirmation of information, background information, medication. Technical problems were found in 44.1%. Positive opinions on user friendliness varied from 73.5% to 100%. No significant difference was found between the user frequency of BOS compared to the NVOG guidelines or local protocol, or between the time needed to consult them. Improvements mentioned by the respondents were mainly regarding the lay-out. Most respondents (85.3%) found it useful to make a computer based support system for other guidelines and 79.4% would also use this. BOS is regarded suitable as an instrument for implementing guidelines and respondents find it useful to develop it for other guidelines as well. Technical problems and poor implementation are important areas of improvement. Copyright © 2012. Published by Elsevier B.V.

GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING): a pilot cluster randomised controlled trial of a guideline implementation intervention for the management of maternal obesity by midwives.

PubMed

Heslehurst, Nicola; Rankin, Judith; McParlin, Catherine; Sniehotta, Falko F; Howel, Denise; Rice, Stephen; McColl, Elaine

2018-01-01

Weight management in pregnancy guidelines exist, although dissemination alone is an ineffective means of implementation. Midwives identify the need for support to overcome complex barriers to practice. An evaluation of an intervention to support midwives' guideline implementation would require a large-scale cluster randomised controlled trial. A pilot study is necessary to explore the feasibility of delivery and evaluation prior to a definitive trial. The GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING) trial aims to test whether it is feasible and acceptable to deliver a behaviour change intervention to support midwives' implementation of weight management guidelines. GLOWING is a multi-centre parallel group pilot cluster randomised controlled trial comparing the delivery of a behaviour change intervention for midwives versus usual practice. Four NHS Trusts (clusters) will be randomised to intervention and control arms, stratified by size of maternity services. The intervention uses social cognitive theory and consists of face-to-face midwifery training plus information resources for routine practice. The main outcomes are whether the intervention and trial procedures are feasible and acceptable to participants and the feasibility of recruitment and data collection for a definitive trial. Target recruitment involves all eligible midwives in the intervention arm recruited to receive the intervention, 30 midwives and pregnant women per arm for baseline and outcome questionnaire data collection and 20 midwives and women to provide qualitative data. All quantitative and qualitative analyses will be descriptive with the purpose of informing the development of the definitive trial. This pilot study has been developed to support community midwives' implementation of guidelines. Community midwives have been selected as they usually carry out the booking appointment which includes measuring and discussing maternal body mass index. A cluster design is the gold standard in implementation research as there would be a high risk of contamination if randomisation was at individual midwife level: community midwives usually work in locality-based teams, interact on a daily basis, and share care of pregnant women. The results of the pilot trial will be used to further develop and refine GLOWING prior to a definitive trial to evaluate effectiveness and cost-effectiveness. ISRCTN46869894; retrospectively registered 25th May 2016.

Quality of clinical practice guidelines in delirium: a systematic appraisal

PubMed Central

Marchington, Katie L; Agar, Meera; Davis, Daniel H J; Sikora, Lindsey; Tsang, Tammy W Y

2017-01-01

Objective To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality. Design Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies. Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a ‘Rigour of Development’ domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Data sources Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search. Results 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II ‘Rigour’ scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were ‘Scope and Purpose’ (mean 80.1%, range 64–100%) and ‘Clarity and Presentation’ (mean 76.7%, range 38–97%). The lowest rating domains were ‘Applicability’ (mean 48.7%, range 8–81%) and ‘Editorial Independence’ (mean 53%, range 2–90%). The three highest rating guidelines in the ‘Applicability’ domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies. Conclusions Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice. PMID:28283488

7 CFR 622.5 - Guidelines.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NEPA (40 CFR parts 1500-1508) issued by the Council on Environmental Quality, and in Economic and Environmental Principles and Guidelines for Water and Related Land Resources Implementation Studies issued by...

Memoranda about Implementation of the Cancer Guidelines and Accompanying Supplemental Guidance - Science Policy Council Cancer Guidelines Implementation Workgroup Communication I and II

EPA Pesticide Factsheets

Memoranda from the Chair of EPA's Science Policy Council to the Science Policy Council and the Science Policy Council Steering Committee regarding Implementation of the Cancer Guidelines and Accompanying Supplemental Guidance.

78 FR 17679 - Implementation of the Updated American Veterinary Medical Association Guidelines for the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-22

... DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health Implementation of the Updated American Veterinary Medical Association Guidelines for the Euthanasia of Animals: 2013 Edition...) awardee institutions on implementation of the American Veterinary Medical Association (AVMA) Guidelines...

An XML-based system for the flexible classification and retrieval of clinical practice guidelines.

PubMed Central

Ganslandt, T.; Mueller, M. L.; Krieglstein, C. F.; Senninger, N.; Prokosch, H. U.

2002-01-01

Beneficial effects of clinical practice guidelines (CPGs) have not yet reached expectations due to limited routine adoption. Electronic distribution and reminder systems have the potential to overcome implementation barriers. Existing electronic CPG repositories like the National Guideline Clearinghouse (NGC) provide individual access but lack standardized computer-readable interfaces necessary for automated guideline retrieval. The aim of this paper was to facilitate automated context-based selection and presentation of CPGs. Using attributes from the NGC classification scheme, an XML-based metadata repository was successfully implemented, providing document storage, classification and retrieval functionality. Semi-automated extraction of attributes was implemented for the import of XML guideline documents using XPath. A hospital information system interface was exemplarily implemented for diagnosis-based guideline invocation. Limitations of the implemented system are discussed and possible future work is outlined. Integration of standardized computer-readable search interfaces into existing CPG repositories is proposed. PMID:12463831

Implementation of the NCSS Guidelines for Teaching Science-Related Social Issues: Exemplar Lessons.

ERIC Educational Resources Information Center

Otto, Robert A., Ed.

This document contains the Guidelines for Teaching Science-Related Social Issues adopted in 1982 by the National Council for the Social Studies and 10 examplar lessons each keyed to particular guidelines and drawing upon contemporary issues. The premise upon which the guidelines are based is that science is a social issue and that the examination…

The CARE guidelines: consensus-based clinical case reporting guideline development

PubMed Central

Gagnier, Joel J; Kienle, Gunver; Altman, Douglas G; Moher, David; Sox, Harold; Riley, David

2013-01-01

A case report is a narrative that describes, for medical, scientific or educational purposes, a medical problem experienced by one or more patients. Case reports written without guidance from reporting standards are insufficiently rigorous to guide clinical practice or to inform clinical study design. Develop, disseminate and implement systematic reporting guidelines for case reports. We used a three-phase consensus process consisting of (1) premeeting literature review and interviews to generate items for the reporting guidelines, (2) a face-to-face consensus meeting to draft the reporting guidelines and (3) postmeeting feedback, review and pilot testing, followed by finalisation of the case report guidelines. This consensus process involved 27 participants and resulted in a 13-item checklist—a reporting guideline for case reports. The primary items of the checklist are title, key words, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, therapeutic interventions, follow-up and outcomes, discussion, patient perspective and informed consent. We believe the implementation of the CARE (CAse REport) guidelines by medical journals will improve the completeness and transparency of published case reports and that the systematic aggregation of information from case reports will inform clinical study design, provide early signals of effectiveness and harms, and improve healthcare delivery. PMID:24155002

Improving occupational physicians' adherence to a practice guideline: feasibility and impact of a tailored implementation strategy.

PubMed

Joosen, Margot C W; van Beurden, Karlijn M; Terluin, Berend; van Weeghel, Jaap; Brouwers, Evelien P M; van der Klink, Jac J L

2015-04-24

Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs' barriers were evaluated. OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs' experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training. The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01). The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs' knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

Implementation of intravenous to oral antibiotic switch therapy guidelines in the general medical wards of a tertiary-level hospital in South Africa.

PubMed

van Niekerk, Anida C; Venter, Daniel J L; Boschmans, Shirley-Anne

2012-03-01

The design and implementation of an antibiotic intravenous (iv) to oral switch therapy (IVOST) guideline in a Third World health setting. The guideline was developed and integrated into daily practice by a ward pharmacist over a period of 7 weeks. Patients were switched once they were deemed clinically stable according to IVOST criteria. The final decision to switch was left to the attending physician. One pre- and two post-implementation audits (150 patient medical records per audit) were compared. Implementation of the IVOST guideline was successful in increasing (P<0.0005) the number of patients switched from 16% (19/119) pre-implementation to 43.9% (47/107) immediately after implementation; however, the change was not sustained 3 months after implementation (20.8%; 25/120). The intervention was also successful in decreasing the overall duration of iv therapy (P<0.0005) from 7.2 ± 3.5 days pre-implementation to 5.2 ± 3.0 days immediately post-implementation. The change was not sustained 3 months after implementation (6.5 ± 3.5 days). Despite the challenges encountered in a Third World environment, an antibiotic IVOST guideline can be successfully implemented. Continual, active integration of the guideline into daily practice by a ward pharmacist is essential if positive IVOST outcomes are to be maintained.

Evaluation of Implementation, Adaptation and Use of the Recently Proposed Urea Cycle Disorders Guidelines.

PubMed

Häberle, Johannes; Huemer, Martina

2015-01-01

Implementation of guidelines and assessment of their adaptation is not an extensively investigated process in the field of rare diseases. However, whether targeted recipients are reached and willing and able to follow the recommendations has significant impact on the efficacy of guidelines. In 2012, a guideline for the management of urea cycle disorders (UCDs) has been published. We evaluate the efficacy of implementation, adaptation, and use of the UCD guidelines by applying different strategies. (i) Download statistics from online sources were recorded. (ii) Facilities relevant for the implementation of the guidelines were assessed in pediatric units in Germany and Austria. (iii) The guidelines were evaluated by targeted recipients using the AGREE instrument. (iv) A regional networking-based implementation process was evaluated. (i) Download statistics revealed high access with an increase in downloads over time. (ii) In 18% of hospitals ammonia testing was not available 24/7, and emergency drugs were often not available. (iii) Recipient criticism expressed in the AGREE instrument focused on incomplete inclusion of patients' perspectives. (iv) The implementation process improved the availability of ammonia measurements and access to emergency medication, patient care processes, and cooperation between nonspecialists and specialists. Interest in the UCD guidelines is high and sustained, but more precise targeting of the guidelines is advisable. Surprisingly, many hospitals do not possess all facilities necessary to apply the guidelines. Regional network and awareness campaigns result in the improvement of both facilities and knowledge.

Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of Qualitative Studies.

PubMed

Slade, Susan C; Kent, Peter; Patel, Shilpa; Bucknall, Tracey; Buchbinder, Rachelle

2016-09-01

Despite the availability of evidence-based guidelines for the management of low back pain (LBP) that contain consistent messages, large evidence-practice gaps in primary care remain. To perform a systematic review and metasynthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for LBP, including perceived enablers and barriers to guideline adherence. Studies investigating perceptions and beliefs about LBP guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis, and synthesized the results in narrative format. Seventeen studies, with a total of 705 participants, were included. We identified 3 key emergent themes and 8 subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; and (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive, and constrained professional practice; however, popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed. Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.

Sustainability of professionals’ adherence to clinical practice guidelines in medical care: a systematic review

PubMed Central

Ament, Stephanie M C; de Groot, Jeanny J A; Maessen, José M C; Dirksen, Carmen D; van der Weijden, Trudy; Kleijnen, Jos

2015-01-01

Objectives To evaluate (1) the state of the art in sustainability research and (2) the outcomes of professionals’ adherence to guideline recommendations in medical practice. Design Systematic review. Data sources Searches were conducted until August 2015 in MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and the Guidelines International Network (GIN) library. A snowball strategy, in which reference sections of other reviews and of included papers were searched, was used to identify additional papers. Eligibility criteria Studies needed to be focused on sustainability and on professionals’ adherence to clinical practice guidelines in medical care. Studies had to include at least 2 measurements: 1 before (PRE) or immediately after implementation (EARLY POST) and 1 measurement longer than 1 year after active implementation (LATE POST). Results The search retrieved 4219 items, of which 14 studies met the inclusion criteria, involving 18 sustainability evaluations. The mean timeframe between the end of active implementation and the sustainability evaluation was 2.6 years (minimum 1.5–maximum 7.0). The studies were heterogeneous with respect to their methodology. Sustainability was considered to be successful if performance in terms of professionals’ adherence was fully maintained in the late postimplementation phase. Long-term sustainability of professionals’ adherence was reported in 7 out of 18 evaluations, adherence was not sustained in 6 evaluations, 4 evaluations showed mixed sustainability results and in 1 evaluation it was unclear whether the professional adherence was sustained. Conclusions (2) Professionals’ adherence to a clinical practice guideline in medical care decreased after more than 1 year after implementation in about half of the cases. (1) Owing to the limited number of studies, the absence of a uniform definition, the high risk of bias, and the mixed results of studies, no firm conclusion about the sustainability of professionals’ adherence to guidelines in medical practice can be drawn. PMID:26715477

Sustainability of professionals' adherence to clinical practice guidelines in medical care: a systematic review.

PubMed

Ament, Stephanie M C; de Groot, Jeanny J A; Maessen, José M C; Dirksen, Carmen D; van der Weijden, Trudy; Kleijnen, Jos

2015-12-29

To evaluate (1) the state of the art in sustainability research and (2) the outcomes of professionals' adherence to guideline recommendations in medical practice. Systematic review. Searches were conducted until August 2015 in MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and the Guidelines International Network (GIN) library. A snowball strategy, in which reference sections of other reviews and of included papers were searched, was used to identify additional papers. Studies needed to be focused on sustainability and on professionals' adherence to clinical practice guidelines in medical care. Studies had to include at least 2 measurements: 1 before (PRE) or immediately after implementation (EARLY POST) and 1 measurement longer than 1 year after active implementation (LATE POST). The search retrieved 4219 items, of which 14 studies met the inclusion criteria, involving 18 sustainability evaluations. The mean timeframe between the end of active implementation and the sustainability evaluation was 2.6 years (minimum 1.5-maximum 7.0). The studies were heterogeneous with respect to their methodology. Sustainability was considered to be successful if performance in terms of professionals' adherence was fully maintained in the late postimplementation phase. Long-term sustainability of professionals' adherence was reported in 7 out of 18 evaluations, adherence was not sustained in 6 evaluations, 4 evaluations showed mixed sustainability results and in 1 evaluation it was unclear whether the professional adherence was sustained. (2) Professionals' adherence to a clinical practice guideline in medical care decreased after more than 1 year after implementation in about half of the cases. (1) Owing to the limited number of studies, the absence of a uniform definition, the high risk of bias, and the mixed results of studies, no firm conclusion about the sustainability of professionals' adherence to guidelines in medical practice can be drawn. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions.

PubMed

Katz, David A; Paez, Monica W; Reisinger, Heather S; Gillette, Meghan T; Weg, Mark W Vander; Titler, Marita G; Nugent, Andrew S; Baker, Laurence J; Holman, John E; Ono, Sarah S

2014-01-24

The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED. We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED. There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. ClinicalTrials.gov registration number NCT00756704.

Experiencing challenges when implementing Active Management of Third Stage of Labor (AMTSL): a qualitative study with midwives in Accra, Ghana

PubMed Central

2014-01-01

Background Post-partum hemorrhage (PPH) is the major cause of maternal mortality in Ghana and worldwide. Active management of the third stage of labor (AMTSL) is a globally recommended three-step method that in clinical trials has been proven effective in prevention of PPH. The AMTSL guidelines were introduced in 2003, modified in 2006, and has been part of the national guidelines in Ghana since 2008. In 2012, the guidelines were modified a second time. Despite its positive effects on the incidence of PPH, the level of adherence to the guidelines seems to be low in the studied area. This appears to be a problem shared by several countries in the region. An in-depth understanding of midwives’ experiences about AMTSL is important as it can provide a basis for further interventions in order to reach a higher grade of implementation. Methods Twelve in-depth interviews were conducted with labor ward midwives who all had previous training in AMTSL. The interviews took place in 2011 at three hospitals in Accra Metropolis and data was analyzed using qualitative latent content analysis. Results Our main finding was that the third step of AMTSL, uterine massage, was not implemented, even though the general attitude towards AMTSL was positive. Thus, despite regular training sessions, the midwives did not follow the Ghanaian national guidelines. Some contributing factors to difficulties in providing AMTSL to all women have been pointed out in this study, the most important being insufficiency in staff coverage. This led to a need for delegating certain steps of AMTSL to other health care staff, i.e. task shifting. The fact that the definition of AMTSL has changed several times since the introduction in 2003 might also be an aggravating factor. Conclusions The results from this study highlight the need for continuous updates of national guidelines, extended educational interventions and recurrent controls of adherence to guidelines. AMTSL is an important tool in preventing PPH, however, it must be clarified how it should be used in countries with scarce resources. Also, considering the difficulties in implementing already existing guidelines, further modifications must be made with careful consideration. PMID:24903893

Implementation of Feeding Guidelines Hastens the Time to Initiation of Enteral Feeds and Improves Growth Velocity in Very Low Birth-Weight Infants.

PubMed

Culpepper, Christine; Hendrickson, Kendra; Marshall, Susan; Benes, Jessica; Grover, Theresa R

2017-04-01

Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown. Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month. Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction. A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group. Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.

Continuing Education, Guideline Implementation, and the Emerging Transdisciplinary Field of Knowledge Translation

ERIC Educational Resources Information Center

Davis, Dave

2006-01-01

This article discusses continuing education and the implementation of clinical practice guidelines or best evidence, quality improvement, and patient safety. Continuing education focuses on the perspective of the adult learner and is guided by well-established educational principles. In contrast, guideline implementation and related concepts…

75 FR 59180 - Approval and Promulgation of Air Quality Implementation Plans; Maryland; Control Technique...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-27

... Promulgation of Air Quality Implementation Plans; Maryland; Control Technique Guidelines for Paper, Film, and... Technique Guidelines (CTG) for paper, film, and foil coatings. These amendments will reduce volatile organic... Promulgation of Air Quality Implementation Plans; Maryland; Control Technique Guidelines for Paper, Film, and...

Osteoarthritis guidelines: Barriers to implementation and solutions.

PubMed

Ferreira de Meneses, Sarah; Rannou, Francois; Hunter, David J

2016-06-01

Osteoarthritis (OA) is a leading cause of disability worldwide. Clinical practice guidelines (CPGs) have been developed to facilitate improved OA management. Scientific communities worldwide have proposed CPGs for OA treatment. Despite the number of highly prominent guidelines available and their remarkable consistency, their uptake has been suboptimal. Possibly because of the multitude of barriers related to the implementation of CPGs. For example, different guidelines show contradictions, some lack evidence, and they lack a hierarchy or tools to facilitate their translation and application. Also, the guidelines do not acknowledge the effect of comorbidities on choosing the treatments. Finally, poor integration of multidisciplinary services within and across healthcare settings is a major barrier to the effective implementation of management guidelines. Here we describe the main problems related to the OA guidelines and some solutions so as to offer some guidance on the elaboration of future CPGs and their implementation in primary care. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Successful implementation of clinical practice guidelines for pressure risk management in a home nursing setting.

PubMed

Kapp, Suzanne

2013-10-01

This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. © 2012 John Wiley & Sons Ltd.

Implementation of a teaching programme to improve doctors' awareness of DVLA guidelines: a multicentre study.

PubMed

Maruthappu, Mahiben; Sykes, Mark; Green, Ben L; Watson, Robert; Gollop, Nicholas D; Shalhoub, Joseph; Ng, Ka Ying Bonnie

2017-02-01

Over half of the UK population holds a driver's licence. Driver and Vehicle Licensing Authority (DVLA) guidelines are available for conditions from most specialties. Despite this, no focused training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching programme to improve guideline awareness. A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later, a single-session teaching programme was implemented. The questionnaire was redistributed. Preintervention and postintervention scores were compared using the Wilcoxon rank sum test. 139 preteaching and 144 post-teaching questionnaires were completed. Implementation of a single-session teaching programme significantly improved the knowledge of DVLA guidelines in all five areas explored. Median scores: neurology, preteaching 40%, post-teaching 100%, p<0.001; cardiology, 0%, 100%, p<0.001; drug and alcohol misuse, 0%, 100%, p<0.001; visual disorders, 40%, 100%, p<0.001; respiratory disorders, 20%, 100%, p<0.001; and overall, 28%, 92%, p<0.001. Knowledge of DVLA guidelines among our cohort was poor. Implementation of a single-session teaching programme can significantly improve guideline knowledge and awareness, serving as a cost-effective intervention. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Value for money in changing clinical practice: should decisions about guidelines and implementation strategies be made sequentially or simultaneously?

PubMed

Hoomans, Ties; Severens, Johan L; Evers, Silvia M A A; Ament, Andre J H A

2009-01-01

Decisions about clinical practice change, that is, which guidelines to adopt and how to implement them, can be made sequentially or simultaneously. Decision makers adopting a sequential approach first compare the costs and effects of alternative guidelines to select the best set of guideline recommendations for patient management and subsequently examine the implementation costs and effects to choose the best strategy to implement the selected guideline. In an integral approach, decision makers simultaneously decide about the guideline and the implementation strategy on the basis of the overall value for money in changing clinical practice. This article demonstrates that the decision to use a sequential v. an integral approach affects the need for detailed information and the complexity of the decision analytic process. More importantly, it may lead to different choices of guidelines and implementation strategies for clinical practice change. The differences in decision making and decision analysis between the alternative approaches are comprehensively illustrated using 2 hypothetical examples. We argue that, in most cases, an integral approach to deciding about change in clinical practice is preferred, as this provides more efficient use of scarce health-care resources.

Thyroidectomy Practice After Implementation of the 2015 American Thyroid Association Guidelines on Surgical Options for Patients With Well-Differentiated Thyroid Carcinoma.

PubMed

Hirshoren, Nir; Kaganov, Kira; Weinberger, Jeffrey M; Glaser, Benjamin; Uziely, Beatrice; Mizrahi, Ido; Eliashar, Ron; Mazeh, Haggi

2018-03-29

The recommended extent of surgery for well-differentiated thyroid carcinoma has been modified considerably in the updated 2015 American Thyroid Association guidelines published in January 2016. To date, the changes in clinical practice after publication of these new guidelines have not been demonstrated. The aim of this study was to evaluate clinical practice changes associated with implementation of the updated guidelines on the surgical procedure rates of total thyroidectomy, thyroid lobectomy, and completion thyroidectomy at a single tertiary medical center. This is a retrospective cohort study of 169 patients at the Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Patients with pathologically proved, well-differentiated thyroid carcinoma who underwent surgery between January 1, 2013, and December 31, 2014, were compared with patients who underwent surgery from January 1 to December 31, 2016. A total of 434 thyroidectomy procedures were performed during the study period, and 251 had pathologically proved, well-differentiated thyroid carcinoma. Patients with tumors larger than 4 cm, involved lymph nodes, or bilateral nodules were excluded. Primary outcomes were the rate of up-front total thyroidectomy vs lobectomy and the rates of completion thyroidectomy before and after the implementation of the new guidelines. Of the 169 patients in the final analysis, 118 (69.8%) were included from 2013 to 2014 and 51 (30.2%) in 2016. The mean (SD) age for the entire cohort was 44 (13.8) years, and 129 (76.3%) were women. Up-front total thyroidectomy was performed in 72 of 118 patients (61.0%) prior to the 2015 American Thyroid Association guidelines and 16 of 51 (31.4%) following their implementation (odds ratio, 0.29; 95% CI, 0.14-0.59). The rate of completion thyroidectomy also significantly decreased between these periods (73.9% vs 20.0%; odds ratio, 0.09; 95% CI, 0.04-0.19). The updated 2015 American Thyroid Association guidelines implementation was associated with a significant decrease in the rates of both up-front total thyroidectomy and completion thyroidectomy. According to these findings, only 1 of 5 patients who undergoes thyroid lobectomy will require a completion procedure.

Barriers to implementing the "2008 Mexican Clinical Practice Guideline recommendations for the management of hip and knee osteoarthritis" in primary healthcare practice.

PubMed

Loyola-Sanchez, Adalberto; Richardson, Julie; Pelaez-Ballestas, Ingris; Sánchez, José Guadalupe; González, Martha Alicia; Sánchez-Cruz, Juan; Jiménez-Baez, María Valeria; Nolasco-Alonso, Nancy; Alvarado, Idolina; Rodríguez-Amado, Jacqueline; Alvarez-Nemegyei, José; Wilson, Mike G

2014-01-01

To evaluate the implementability of the "2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care" within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2). Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques. Reviewers' agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients' beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline. The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Implementing change in primary care practices using electronic medical records: a conceptual framework.

PubMed

Nemeth, Lynne S; Feifer, Chris; Stuart, Gail W; Ornstein, Steven M

2008-01-16

Implementing change in primary care is difficult, and little practical guidance is available to assist small primary care practices. Methods to structure care and develop new roles are often needed to implement an evidence-based practice that improves care. This study explored the process of change used to implement clinical guidelines for primary and secondary prevention of cardiovascular disease in primary care practices that used a common electronic medical record (EMR). Multiple conceptual frameworks informed the design of this study designed to explain the complex phenomena of implementing change in primary care practice. Qualitative methods were used to examine the processes of change that practice members used to implement the guidelines. Purposive sampling in eight primary care practices within the Practice Partner Research Network-Translating Researching into Practice (PPRNet-TRIP II) clinical trial yielded 28 staff members and clinicians who were interviewed regarding how change in practice occurred while implementing clinical guidelines for primary and secondary prevention of cardiovascular disease and strokes. A conceptual framework for implementing clinical guidelines into primary care practice was developed through this research. Seven concepts and their relationships were modelled within this framework: leaders setting a vision with clear goals for staff to embrace; involving the team to enable the goals and vision for the practice to be achieved; enhancing communication systems to reinforce goals for patient care; developing the team to enable the staff to contribute toward practice improvement; taking small steps, encouraging practices' tests of small changes in practice; assimilating the electronic medical record to maximize clinical effectiveness, enhancing practices' use of the electronic tool they have invested in for patient care improvement; and providing feedback within a culture of improvement, leading to an iterative cycle of goal setting by leaders. This conceptual framework provides a mental model which can serve as a guide for practice leaders implementing clinical guidelines in primary care practice using electronic medical records. Using the concepts as implementation and evaluation criteria, program developers and teams can stimulate improvements in their practice settings. Investing in collaborative team development of clinicians and staff may enable the practice environment to be more adaptive to change and improvement.

Uptake of the World Health Organization’s trauma care guidelines: a systematic review

PubMed Central

Riggle, Kevin; Joshipura, Manjul; Quansah, Robert; Reynolds, Teri; Sherr, Kenneth; Mock, Charles

2016-01-01

Abstract Objective To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. Methods We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines – Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes – were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines’ implementation. Findings We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries – 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions. Conclusion Although WHO’s trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed. PMID:27516636

A comparison of guidelines for the treatment of schizophrenia.

PubMed

Milner, Karen K; Valenstein, Marcia

2002-07-01

Although the clinical and administrative rationales for the use of guidelines in the treatment of schizophrenia are convincing, meaningful implementation has been slow. Guideline characteristics themselves influence whether implementation occurs. The authors examine three widely distributed guidelines and one set of algorithms to compare characteristics that are likely to influence implementation, including their degree of scientific rigor, comprehensiveness, and clinical applicability (ease of use, timeliness, specificity, and ease of operationalizing). The three guidelines are the Expert Consensus Guideline Series' "Treatment of Schizophrenia"; the American Psychiatric Association's "Practice Guideline for the Treatment of Patients With Schizophrenia"; and the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. The algorithms are those of the Texas Medication Algorithm Project (TMAP). The authors outline the strengths of each and suggest how a future guideline might build on these strengths.

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda.

PubMed

Kane, Jeremy C; Adaku, Alex; Nakku, Juliet; Odokonyero, Raymond; Okello, James; Musisi, Seggane; Augustinavicius, Jura; Greene, M Claire; Alderman, Steve; Tol, Wietse A

2016-03-15

In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda. In-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews. Practices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients. Guidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study.

PubMed

Barker, Anna Lucia; Kamar, Jeannette; Tyndall, Tamara Jane; White, Lyn; Hutchinson, Anastasia; Klopfer, Nicole; Weller, Carolina

2013-06-01

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9-year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual-care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital-acquired pressure ulcers decreased following implementation of an evidence-based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual-care nurses under-estimated patients' risk of pressure ulcer development and under-utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital-acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital. © 2012 The Authors. International Wound Journal © 2012 John Wiley & Sons Ltd and Medicalhelplines.com Inc.

Building Chronic Kidney Disease Clinical Practice Guidelines Using the openEHR Guideline Definition Language.

PubMed

Lin, Ching-Heng; Lo, Ying-Chih; Hung, Pei-Yuan; Liou, Der-Ming

2016-12-07

As a result of the disease's high prevalence, chronic kidney disease (CKD) has become a global public health problem. A clinical decision support system that integrates with computer-interpretable guidelines (CIGs) should improve clinical outcomes and help to ensure patient safety. The openEHR guideline definition language (GDL) is a formal language used to represent CIGs. This study explores the feasibility of using a GDL approach for CKD; it also attempts to identify any potential gaps between the ideal concept and reality. Using the Kidney Disease Improving Global Outcomes (KDIGO) anemia guideline as material, we designed a development workflow in order to establish a series of GDL guidelines. Focus group discussions were conducted in order to identify important issues related to GDL implementation. Ten GDL guidelines and 37 archetypes were established using the KDIGO guideline document. For the focus group discussions, 16 clinicians and 22 IT experts were recruited and their perceptions, opinions and attitudes towards the GDL approach were explored. Both groups provided positive feedback regarding the GDL approach, but raised various concerns about GDL implementation. Based on the findings of this study, we identified some potential gaps that might exist during implementation between the GDL concept and reality. Three directions remain to be investigated in the future. Two of them are related to the openEHR GDL approach. Firstly, there is a need for the editing tool to be made more sophisticated. Secondly, there needs to be integration of the present approach into non openEHR-based hospital information systems. The last direction focuses on the applicability of guidelines and involves developing a method to resolve any conflicts that occur with insurance payment regulations.

Not of One Mind: Mental Models of Clinical Practice Guidelines in the Veterans Health Administration

PubMed Central

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-01-01

Objective The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Data Sources Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. Study Design This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. Data Collection A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Findings Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. Conclusions We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care. PMID:15960693

Implementation guidelines for road weather information systems

DOT National Transportation Integrated Search

1997-11-01

The report presents guidelines for implementing road weather information systems (RWIS). These guidelines will assist highway agency personnel with the planning, installation, and maintenance of road weather information systems for either ice or high...

A Qualitative Study of Provider Perceptions of Influences on Uptake of Pediatric Hospital Guidelines in Lao PDR.

PubMed

Gray, Amy Z; Soukaloun, Douangdao; Soumphonphakdy, Bandith

2017-08-01

Strategies to improve the quality of hospital care are needed if ongoing gains in child health and survival are to be made. We previously reported on improvements in the quality of case management in hospitals following a guideline-based intervention in Lao PDR, with variation in the degree of change achieved between clinical conditions. This study aims to understand the factors that influenced the uptake of the guideline-based intervention, and its impact on care. This qualitative study was embedded in a mixed-methods evaluation of guideline implementation in nine hospitals in Lao PDR. Focus groups and individual interviews were conducted with 70 health staff from central, provincial, and district hospitals. The interview guide was based on the Theoretical Domains Framework. Inductive content analysis was performed on interview transcripts to identify themes, supported by field notes from the intervention. Findings were triangulated against previously reported quantitative outcomes using driver diagrams. Key influences on guidelines uptake related to the guideline and intervention (filling a void, physical accessibility, comprehensibility, training in guideline use), health staff (behavior regulation, trust in guidelines, and beliefs about consequences), and the environment (social influences particularly consensus and incorporation into clinical norms). The major barrier was family preference for treatments in conflict with guideline recommendations. This study identifies contextual factors that explain, as well as validate previously identified improvements in care following guideline implementation in Lao PDR. It provides novel understanding of why the same intervention may have a differential impact on different clinical conditions.

The clinical database and implementation of treatment guidelines by the Danish Breast Cancer Cooperative Group in 2007-2016.

PubMed

Jensen, Maj-Britt; Laenkholm, Anne-Vibeke; Offersen, Birgitte V; Christiansen, Peer; Kroman, Niels; Mouridsen, Henning T; Ejlertsen, Bent

2018-01-01

Since 40 years, Danish Breast Cancer Cooperative Group (DBCG) has provided comprehensive guidelines for diagnosis and treatment of breast cancer. This population-based analysis aimed to describe the plurality of modifications introduced over the past 10 years in the national Danish guidelines for the management of early breast cancer. By use of the clinical DBCG database we analyze the effectiveness of the implementation of guideline revisions in Denmark. From the DBCG guidelines we extracted modifications introduced in 2007-2016 and selected examples regarding surgery, radiotherapy (RT) and systemic treatment. We assessed introduction of modifications from release on the DBCG webpage to change in clinical practice using the DBCG clinical database. Over a 10-year period data from 48,772 patients newly diagnosed with malignant breast tumors were entered into DBCG's clinical database and 42,197 of these patients were diagnosed with an invasive carcinoma following breast conserving surgery (BCS) or mastectomy. More than twenty modifications were introduced in the guidelines. Implementations, based on prospectively collected data, varied widely; exemplified with around one quarter of the patients not treated according to a specific guideline within one year from the introduction, to an almost immediate full implantation. Modifications of the DBCG guidelines were generally well implemented, but the time to full implementation varied from less than one year up to around five years. Our data is registry based and does not allow a closer analysis of the causes for delay in implementation of guideline modifications.

Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians

PubMed Central

Salinas, Gregory D; Williamson, James C; Kalhan, Ravi; Thomashow, Byron; Scheckermann, Jodi L; Walsh, John; Abdolrasulnia, Maziar; Foster, Jill A

2011-01-01

Purpose: Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines. Patients and methods: A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage. Results: Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response. Conclusions: Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence. PMID:21468169

Guidelines for Conducting and Reporting Mixed Research in the Field of Counseling and beyond

ERIC Educational Resources Information Center

Leech, Nancy L.; Onwuegbuzie, Anthony J.

2010-01-01

This article provides guidelines for conducting, reporting, and evaluating mixed research studies in 3 sections: research formulation, research planning, and research implementation. To date, no such guidelines are available. Detailed descriptions of each subsection are included. The authors hope that these standards assist researchers from the…

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice.

PubMed

Medves, Jennifer; Godfrey, Christina; Turner, Carly; Paterson, Margo; Harrison, Margaret; MacKenzie, Lindsay; Durando, Paola

2010-06-01

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice. Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion. Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies. Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes. © 2010 The Authors. Journal Compilation © Blackwell Publishing Asia Pty Ltd.

From guidelines to local realities: evaluation of oral rehydration therapy and zinc supplementation in Guatemala.

PubMed

Hall-Clifford, Rachel; Amerson, Roxanne

2017-04-20

Diarrhea remains a leading cause of morbidity and mortality for children in low- and middle-income countries throughout the Americas. The World Health Organization (WHO) has developed guidelines on incorporating zinc supplementation (ZS) with traditional oral rehydration therapy (ORT) in order to shorten the duration of diarrheal episodes and to reduce poor health outcomes. Guatemala adopted these guidelines in 2011, but they have not yet been fully implemented at the community level. The objectives of this study were: (1) to co-design an ORT/ZS training program for community members with local health promoters that is appropriate to the local context and (2) to understand how attitudes and behaviors of community members changed after receiving training from the study promoters. In an observational study, community health promoters in rural Guatemala were trained according to WHO guidelines, and they worked collaboratively with the study team to develop a training curriculum to implement in their community. Community-based surveys, interviews, and focus group discussions were used to assess acceptability, accessibility, and availability of oral rehydration therapy and zinc supplementation. Use of ORT increased from 63% to 95% among community members following training by local health promoters. Satisfaction with the service offered by health promoters increased from 63% to 90% amongst community members trained by the study promoters. However, knowledge and use of zinc supplementation remained low, which was attributable to unavailability of zinc in the study community. Use of trained community health promoters is an effective way to translate WHO guidelines to local contexts and overcome sociocultural barriers to care. However, the health system's structure must support availability of essential medicines in order to effectively implement those guidelines.

NSPWG-recommended safety requirements and guidelines for SEI nuclear propulsion

NASA Technical Reports Server (NTRS)

Marshall, Albert C.; Sawyer, J. C., Jr.; Bari, Robert A.; Brown, Neil W.; Cullingford, Hatice S.; Hardy, Alva C.; Lee, James H.; Mcculloch, William H.; Niederauer, George F.; Remp, Kerry

1992-01-01

An interagency Nuclear Safety Policy Working Group (NSPWG) was chartered to recommend nuclear safety policy, requirements, and guidelines for the Space Exploration Initiative (SEI) nuclear propulsion program to facilitate the implementation of mission planning and conceptual design studies. The NSPWG developed a top-level policy to provide the guiding principles for the development and implementation of the nuclear propulsion safety program and the development of safety functional requirements. In addition, the NSPWG reviewed safety issues for nuclear propulsion and recommended top-level safety requirements and guidelines to address these issues. Safety requirements were developed for reactor start-up, inadvertent criticality, radiological release and exposure, disposal, entry, and safeguards. Guidelines were recommended for risk/reliability, operational safety, flight trajectory and mission abort, space debris and meteoroids, and ground test safety. In this paper the specific requirements and guidelines will be discussed.

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review

PubMed Central

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R. Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-01-01

Background The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. Methods We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. Results We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Conclusion Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. PMID:29511005

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review.

PubMed

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-03-06

The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol.

PubMed

MacFarlane, Anne; O'Donnell, Catherine; Mair, Frances; O'Reilly-de Brún, Mary; de Brún, Tomas; Spiegel, Wolfgang; van den Muijsenbergh, Maria; van Weel-Baumgarten, Evelyn; Lionis, Christos; Burns, Nicola; Gravenhorst, Katja; Princz, Christine; Teunissen, Erik; van den Driessen Mareeuw, Francine; Saridaki, Aristoula; Papadakaki, Maria; Vlahadi, Maria; Dowrick, Christopher

2012-11-20

The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology--Participatory Learning and Action--to investigate and support implementation of such guidelines and training initiatives in routine practice. This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders-migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory's four constructs--coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings. This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Implementing tobacco use treatment guidelines in public health dental clinics in New York City.

PubMed

Shelley, Donna; Anno, Jaime; Tseng, Tuo-Yen; Calip, Greg; Wedeles, John; Lloyd, Madeleine; Wolff, Mark S

2011-04-01

In this study we evaluated the effect of a multicomponent intervention to implement the Public Health Service (PHS) guideline Treating Tobacco Use and Dependence in six randomly selected dental clinics in New York University's College of Dentistry. The main outcome measure-provider adherence to tobacco use treatment guidelines-was assessed by auditing a random selection of patient charts pre (698) and post (641) intervention. The intervention components included a chart reminder and referral system, free nicotine replacement therapy (NRT), and provider training and feedback. The results showed that rates of screening for tobacco use did not change between pre and post test chart audits. However, providers were significantly more likely to offer advice (28.4 percent pre, 49 percent post), assess readiness to quit (17.8 percent pre, 29.9 percent post), and offer assistance (6.5 percent pre and 15.6 percent post) in the post test period. Increases in NRT distribution were associated with booster training sessions but declined in the time periods between those trainings. Research is needed to further define sustainable strategies for implementing tobacco use treatment in dental clinics. The results of this study suggest the feasibility and effectiveness of using a tailored multicomponent approach to implement tobacco use treatment guidelines in dental clinics.

Perceived value of applying Information Communication Technology to implement guidelines in developing countries; an online questionnaire study among public health workers.

PubMed

Machingura, Pasipanodya Ian; Adekola, Olawumi; Mueni, Eunice; Oaiya, Omo; Gustafsson, Lars L; Heller, Richard F

2014-01-01

Practice guidelines can be used to support healthcare decision making. We sought to identify the use, and barriers to the implementation, of electronic based guidelines to support decision-making in maternal and child healthcare (MCH) and the rational use of medicines, in developing countries. Graduates who had gained the Master of Public Health degree through the Peoples-uni (postgraduate public health education in developing countries) were sent an online survey questionnaire which had been piloted. Two reminders were sent to non-respondents at intervals of 10 days. Results were explored using descriptive analyses. 44 of the potential 48 graduates from 16 countries responded - most were from Africa. 82% and 89% of respondents were aware of guidelines on MCH and the rational use of medicines respectively. Electronic guidelines were more available in university hospitals than in provincial hospitals or rural care. All respondents thought that guidelines could improve the delivery of quality care, and 42 (95%) and 41 (93%) respectively thought that computers and mobile or smartphones could increase the use of guidelines in service delivery. Lack of access to computers, need to buy phone credit, need for training in the use of either computerized or phone based guidelines and fear of increased workload were potential barriers to use. There is support for the use of electronic guidelines despite limited availability and barriers to use in developing countries. These findings, and other literature, provide a guide as to how the further development of ICT based guidelines may be implemented to improve health care decision making.

The iSCREEN Electronic Diabetes Dashboard: A Tool to Improve Knowledge and Implementation of Pediatric Clinical Practice Guidelines.

PubMed

Zahanova, Stacy; Tsouka, Alexandra; Palmert, Mark R; Mahmud, Farid H

2017-12-01

Clinical practice guidelines (CPG) provide evidence-based recommendations for patient care but may not be optimally applied in clinical settings. As a pilot study, we evaluated the impact of a computerized, point-of-care decision support system (CDSS) on guideline knowledge and adherence in our diabetes clinic. iSCREEN, a CDSS, integrated with a province-wide electronic health record, was designed based on the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Evaluation data were gathered by retrospective chart review and clinician questionnaire prior to and after implementation of iSCREEN. Records of patients with type 1 diabetes, 14 to 18 years of age, were assessed for appropriate screening for complications and comorbidities. To assess guideline adherence, 50 charts were reviewed at 2 time periods (25 before and 25 after launch of iSCREEN). Results revealed improved frequency of appropriate screening for diabetic nephropathy (p=0.03) and retinopathy (p=0.04), accompanied by a decrease in under- and overscreening for these outcomes. To assess guideline knowledge, 58 surveys were collected (31 prior to and 27 after the launch of iSCREEN) from care providers in the field of pediatric diabetes. There was a trend toward improved guideline knowledge in all team members (p=0.06). Implementation of a de novo CDSS was associated with improved rates of appropriate screening for diabetes-related complications. A trend toward improvement in health professionals' knowledge of the guidelines was also observed. Evaluation of this point-of-care computerized decision support tool suggests that it may facilitate diabetes care by optimizing complication screening and CPG knowledge, with the potential for broader implementation. Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.

Implementing Same Day Discharge Following Percutaneous Coronary Intervention: A Process Evaluation.

PubMed

Chen, Yingyan; Lin, Frances; Marshall, Andrea

2018-06-14

The safety and effectiveness of same day discharge (SDD) following percutaneous coronary intervention are well demonstrated; however, the uptake of this model of care is low. The aim was to examine the effectiveness of implementing SDD using a process evaluation methodology. This study was undertaken in a cardiac services department of a tertiary teaching hospital in southeast Queensland, Australia. It was anticipated before the implementation that 120 patients could be discharged the same day in a 6 months' time period. Patient selection process and guideline adherence were assessed along with patients' and relatives' satisfaction. During implementation, 22 patients were discharged home the same day. It was found that staff did not follow the guideline consistently, with an overall adherence of 77.3%. The uptake of SDD was low in this implementation. The study is important as it provides direction for future improvement both in the criteria and the implementation process.

Quality of clinical practice guidelines in delirium: a systematic appraisal.

PubMed

Bush, Shirley H; Marchington, Katie L; Agar, Meera; Davis, Daniel H J; Sikora, Lindsey; Tsang, Tammy W Y

2017-03-10

To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality. Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a 'Rigour of Development' domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search. 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II 'Rigour' scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were 'Scope and Purpose' (mean 80.1%, range 64-100%) and 'Clarity and Presentation' (mean 76.7%, range 38-97%). The lowest rating domains were 'Applicability' (mean 48.7%, range 8-81%) and 'Editorial Independence' (mean 53%, range 2-90%). The three highest rating guidelines in the 'Applicability' domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies. Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

The value of theory in programmes to implement clinical guidelines: Insights from a retrospective mixed-methods evaluation of a programme to increase adherence to national guidelines for chronic disease in primary care

PubMed Central

Sheringham, Jessica; Solmi, Francesca; Ariti, Cono; Baim-Lance, Abigail; Morris, Steve; Fulop, Naomi J.

2017-01-01

Background Programmes have had limited success in improving guideline adherence for chronic disease. Use of theory is recommended but is often absent in programmes conducted in ‘real-world’ rather than research settings. Materials and methods This mixed-methods study tested a retrospective theory-based approach to evaluate a ‘real-world’ programme in primary care to improve adherence to national guidelines for chronic obstructive pulmonary disease (COPD). Qualitative data, comprising analysis of documents generated throughout the programme (n>300), in-depth interviews with planners (clinicians, managers and improvement experts involved in devising, planning, and implementing the programme, n = 14) and providers (practice clinicians, n = 14) were used to construct programme theories, experiences of implementation and contextual factors influencing care. Quantitative analyses comprised controlled before-and-after analyses to test ‘early’ and evolved’ programme theories with comparators grounded in each theory. ‘Early’ theory predicted the programme would reduce emergency hospital admissions (EHA). It was tested using national analysis of standardized borough-level EHA rates between programme and comparator boroughs. ‘Evolved’ theory predicted practices with higher programme participation would increase guideline adherence and reduce EHA and costs. It was tested using a difference-in-differences analysis with linked primary and secondary care data to compare changes in diagnosis, management, EHA and costs, over time and by programme participation. Results Contrary to programme planners’ predictions in ‘early’ and ‘evolved’ programme theories, admissions did not change following the programme. However, consistent with ‘evolved’ theory, higher guideline adoption occurred in practices with greater programme participation. Conclusions Retrospectively constructing theories based on the ideas of programme planners can enable evaluators to address some limitations encountered when evaluating programmes without a theoretical base. Prospectively articulating theory aided by existing models and mid-range implementation theories may strengthen guideline adoption efforts by prompting planners to scrutinise implementation methods. Benefits of deriving programme theory, with or without the aid of mid-range implementation theories, however, may be limited when the evidence underpinning guidelines is flawed. PMID:28328942

Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels.

PubMed

Walder, B; Francioli, D; Meyer, J J; Lançon, M; Romand, J A

2000-07-01

Because of around-the-clock activities, environmental noise and light are among the many causes of sleep disturbance in an intensive care unit (ICU). The implementation of guidelines may potentially change behavior rules and improve sleep quality. A prospective interventional study, observing the effects of simple nighttime guidelines on light and noise levels in an ICU. A modern surgical ICU, subdivided into six identical three-bed rooms. Critically ill adult patients. Between two observation periods, five guidelines were implemented to decrease both light and noise during the night shift in the patient's room. Light levels and noise levels were obtained using a luxmeter and a sound level meter [A-weighted decibels (dB) scale] and were monitored continuously from 11 pm to 5 am both before (period P1) and after (period P2) the implementation of guidelines. Similar patient's gravity and nursing workload scores were observed between P1 and P2. A low mean (<5 Lux) and maximal light level were measured during both P1 and P2. The implementation of guidelines lowered mean light disturbance intensity with a greater variability of light during P2. All noise levels were high and corresponded more to a quiet office for noise level equivalents and to a busy restaurant for peak noise levels during both P1 and P2. Guidelines decreased the noise level equivalent (P1, 51.3 dB; P2, 48.3 dB), peak noise level (P1, 74.9 dB; P2, 70.8 dB), and the number of acoustic identified alarms (P1, 22.1 dB; P2, 15.8 dB) during P2. The night light levels were low during both periods, and lowering the light levels induced a greater variation of light, which may impair sleep quality. All measured noise levels were high during both periods, which could contribute to sleep disturbance, and the implementation of guidelines significantly lowers some important noise levels. The background noise level was unchanged.

Implementation of the SSHAC Guidelines for Level 3 and 4 PSHAs - Experience Gained from Actual Applications

USGS Publications Warehouse

Hanks, Thomas C.; Abrahamson, Norm A.; Boore, David M.; Coppersmith, Kevin J.; Knepprath, Nichole E.

2009-01-01

In April 1997, after four years of deliberations, the Senior Seismic Hazard Analysis Committee released its report 'Recommendations for Probabilistic Seismic Hazard Analysis: Guidance on Uncertainty and Use of Experts' through the U.S. Nuclear Regulatory Commission as NUREG/CR-6372, hereafter SSHAC (1997). Known informally ever since as the 'SSHAC Guidelines', SSHAC (1997) addresses why and how multiple expert opinions - and the intrinsic uncertainties that attend them - should be used in Probabilistic Seismic Hazard Analyses (PSHA) for critical facilities such as commercial nuclear power plants. Ten years later, in September 2007, the U.S. Geological Survey (USGS) entered into a 13-month agreement with the U.S. Nuclear Regulatory Commission (NRC) titled 'Practical Procedures for Implementation of the SSHAC Guidelines and for Updating PSHAs'. The NRC was interested in understanding and documenting lessons learned from recent PSHAs conducted at the higher SSHAC Levels (3 and 4) and in gaining input from the seismic community for updating PSHAs as new information became available. This study increased in importance in anticipation of new applications for nuclear power facilities at both existing and new sites. The intent of this project was not to replace the SSHAC Guidelines but to supplement them with the experience gained from putting the SSHAC Guidelines to work in practical applications. During the course of this project, we also learned that updating PSHAs for existing nuclear power facilities involves very different issues from the implementation of the SSHAC Guidelines for new facilities. As such, we report our findings and recommendations from this study in two separate documents, this being the first. The SSHAC Guidelines were written without regard to whether the PSHAs to which they would be applied were site-specific or regional in scope. Most of the experience gained to date from high-level SSHAC studies has been for site-specific cases, although three ongoing (as of this writing) studies are regional in scope. Updating existing PSHAs will depend more critically on the differences between site-specific and regional studies, and we will also address these differences in more detail in the companion report. Most of what we report here and in the second report on updating PSHAs emanates from three workshops held by the USGS at their Menlo Park facility: 'Lessons Learned from SSHAC Level 3 and 4 PSHAs' on January 30-31, 2008; 'Updates to Existing PSHAs' on May 6-7, 2008; and 'Draft Recommendations, SSHAC Implementation Guidance' on June 4-5, 2009. These workshops were attended by approximately 40 scientists and engineers familiar with hazard studies for nuclear facilities. This company included four of the authors of SSHAC (1997) and four other experts whose contributions to this document are mentioned in the Acknowledgments section; numerous scientists and engineers who in one role or another have participated in one or more high-level SSHAC PSHAs summarized later in this report; and representatives of the nuclear industry, the consulting world, the regulatory community, and academia with a keen interest and expertise in hazard analysis. This report is a community-based set of recommendations to NRC for improved practical procedures for implementation of the SSHAC Guidelines. In an early publication specifically addressing the SSHAC Guidelines, Hanks (1997) noted that the SSHAC Guidelines were likely to evolve for some time to come, and this remains true today. While the broad philosophical and theoretical dimensions of the SSHAC Guidelines will not change, much has been learned during the past decade from various applications of the SSHAC Guidelines to real PSHAs in terms of how they are implemented. We anticipate that, in their practical applications, the SSHAC Guidelines will continue to evolve as more experience is gained from future SSHAC applications. Indeed, to the extent that every PSHA has its

Evaluation of clinical practice guidelines.

PubMed Central

Basinski, A S

1995-01-01

Compared with the current focus on the development of clinical practice guidelines the effort devoted to their evaluation is meagre. Yet the ultimate success of guidelines depends on routine evaluation. Three types of evaluation are identified: evaluation of guidelines under development and before dissemination and implementation, evaluation of health care programs in which guidelines play a central role, and scientific evaluation, through studies that provide the scientific knowledge base for further evolution of guidelines. Identification of evaluation and program goals, evaluation design and a framework for evaluation planning are discussed. PMID:7489550

[Considerations on the development of nutrition-related guidelines by the World Health Organization and their implementation].

PubMed

Zamora, Gerardo; Meneses, Daniela; De-Regil, Luz Maria; Neufeld, Lynnette; Peña-Rosas, Juan Pablo; Sinisterra, Odalis Teresa

2015-03-01

The World Health Organization (WHO) follows a complex and rigorous process to develop global guidelines. With regard to nutrition-related guidelines, the joint participation of national authorities from Member States and their partners, including those of the social economy, is key to strengthening the process of evidence-informed guideline development and the subsequent implementation as part of national public health strategies. WHO puts forward a series of tools that can assist national authorities on health and social development in the elaboration of evidence-informed policies, considering their pertinence, relevance and implementability. This adoption and adaptation process must consider equity in order to avoid widening existing inequities. WHO global nutrition guidelines contribute to the effective implementation of nutrition interventions in Member States. Two experiences of implementation, one in Panama and one in Peru, exemplify this process. The paper ends by suggesting a deeper understanding and utilization of implementation research during programmes to identify what factors ensure effective interventions, appropriate scale up strategies and greater health equity.

[Guideline implementation study on asthma: Results of a pragmatic implementation approach].

PubMed

Redaèlli, Marcus; Vollmar, Horst Christian; Simic, Dusan; Maly-Schürer, Cornelia; Löscher, Susanne; Koneczny, Nikolaus

2015-01-01

Knowledge transfer from theory to practice in healthcare systems poses a challenge worldwide. Typical examples include national disease management guidelines. The present study contributes towards improving implementation strategies for an asthma guideline. A guideline implementation strategy was examined in a four-armed, non-randomised, controlled intervention study with an additional control group. The study participants were general practitioners and paediatricians recruited from primary care quality circles. All study participants attended an interactive seminar on the evidence-based recommendations for patients with asthma. In addition, the participants were asked to choose among the following options: no further intervention, additional e-learning, training of their practice nurses, or e-learning and training of their practice nurses. The success of the intervention was measured by questionnaire (and the success rate expressed as a percentage). About one third of all participants (n=313) opted for the combination of an interactive seminar and a training of practice nurses; two third preferred the classic way of continuing medical education with an interactive seminar without a further intervention. Just 10 % of the physicians participated in e-learning. Independently of their choice for continuing medical education, all participants demonstrated an increase in knowledge about asthma and an improvement in the management of asthma. The physicians exhibited an average increase in both categories of about 10 % of the percentage values, compared to an increase of about 28 % among the practice nurses without continuing medical education. The physicians' free choice of the educative modules might be an integral part of successful implementation strategies. However, this will require a change of focus from general continuing medical education packages to a more individualised culture of continuing professional development in Germany. Copyright © 2015. Published by Elsevier GmbH.

Non-vitamin K antagonist oral anticoagulants and atrial fibrillation guidelines in practice: barriers to and strategies for optimal implementation

PubMed Central

Camm, A. John; Pinto, Fausto J.; Hankey, Graeme J.; Andreotti, Felicita; Hobbs, F.D. Richard

2015-01-01

Stroke is a leading cause of morbidity and mortality worldwide. Atrial fibrillation (AF) is an independent risk factor for stroke, increasing the risk five-fold. Strokes in patients with AF are more likely than other embolic strokes to be fatal or cause severe disability and are associated with higher healthcare costs, but they are also preventable. Current guidelines recommend that all patients with AF who are at risk of stroke should receive anticoagulation. However, despite this guidance, registry data indicate that anticoagulation is still widely underused. With a focus on the 2012 update of the European Society of Cardiology (ESC) guidelines for the management of AF, the Action for Stroke Prevention alliance writing group have identified key reasons for the suboptimal implementation of the guidelines at a global, regional, and local level, with an emphasis on access restrictions to guideline-recommended therapies. Following identification of these barriers, the group has developed an expert consensus on strategies to augment the implementation of current guidelines, including practical, educational, and access-related measures. The potential impact of healthcare quality measures for stroke prevention on guideline implementation is also explored. By providing practical guidance on how to improve implementation of the ESC guidelines, or region-specific modifications of these guidelines, the aim is to reduce the potentially devastating impact that stroke can have on patients, their families and their carers. PMID:26116685

Cancer cachexia: global awareness and guideline implementation on the web.

PubMed

Mauri, Davide; Tsiara, Anna; Valachis, Antonis; Kalopita, Konstantina; Tsali, Lampriani; Tolis, Panagiotis; Polyzos, Nikolaos P

2013-06-01

Cancer cachexia is a common associate of cancer and has a negative impact on patients' survival. Nonetheless, cancer cachexia assessment and management are frequently less than satisfactory in daily practice. To scrutinise global cancer cachexia awareness and relative web guideline implementation among oncology societies. Systematical identification of scientific and policymaker oncology societies and their guideline implementation on cancer cachexia. Assessment of the general level of awareness on cancer cachexia and evaluation of intercontinental and national variations on guideline implementation. 144,000 web pages were scrutinised, and 275 oncology societies identified covering a large array of oncology setting (educational/clinical/research/policymaker); 71 were international (African, American, Asian, European, Oceania and Intercontinental), 110 belonged to the top 10 countries with the highest development index and 94 pertained to 10 countries with a long lasting tradition in medical oncology (not included in the top 10 high developed countries). Overall, only 10/275 web sites provided guidelines; six of them (2.2%) provided guidelines for physicians and four (0.7%) for patients. Half of the guidelines (4/10) were outdated. All guidelines for physicians reported references, while only one of the recommendations for patients reported references to support its sentences. Cancer cachexia global awareness appears extremely low; guideline implementation on the web was inconsistent for any category analysed (nation vs continent vs international vs society type vs physician vs patient oriented) and for updating.

Guidelines in lower-middle income countries.

PubMed

Olayemi, Edeghonghon; Asare, Eugenia V; Benneh-Akwasi Kuma, Amma A

2017-06-01

Guidelines include recommendations intended to optimize patient care; used appropriately, they make healthcare consistent and efficient. In most lower-middle income countries (LMICs), there is a paucity of well-designed guidelines; as a result, healthcare workers depend on guidelines developed in Higher Income Countries (HICs). However, local guidelines are more likely to be implemented because they are applicable to the specific environment; and consider factors such as availability of resources, specialized skills and local culture. If guidelines developed in HICs are to be implemented in LMICs, developers need to incorporate local experts in their development. Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to implementation in LMICs. Another option is to encourage local experts to adapt them for use in LMICs; these guidelines may recommend strategies different from those used in HICs, but will be aimed at achieving the best practicable standard of care. Infrastructural deficits in LMICs could be improved by learning from and building on the successful response to the human immunodeficiency virus/acquired immunodeficiency syndrome pandemic through interactions between HICs and LMICs. Similarly, collaborations between postgraduate medical colleges in both HICs and LMICs may help specialist doctors training in LMICs develop skills required for guideline development and implementation. © 2017 John Wiley & Sons Ltd.

Providers' perceptions of spinal cord injury pressure ulcer guidelines.

PubMed

Thomason, Susan S; Evitt, Celinda P; Harrow, Jeffrey J; Love, Linda; Moore, D Helen; Mullins, Maria A; Powell-Cope, Gail; Nelson, Audrey L

2007-01-01

Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators. This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators. The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources. Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.

Tailoring International Pressure Ulcer Prevention Guidelines for Nigeria: A Knowledge Translation Study Protocol.

PubMed

Ilesanmi, Rose Ekama; Gillespie, Brigid M; Adejumo, Prisca Olabisi; Chaboyer, Wendy

2015-07-28

The 2014 International Pressure Ulcer Prevention (PUP) Clinical Practice Guidelines (CPG) provides the most current evidence based strategies to prevent Pressure Ulcer (PU). The evidence upon which these guidelines have been developed has predominantly been generated from research conducted in developed countries. Some of these guidelines may not be feasible in developing countries due to structural and resource issues; therefore there is a need to adapt these guidelines to the context thus making it culturally acceptable. To present a protocol detailing the tailoring of international PUPCPG into a care bundle for the Nigerian context. Guided by the Knowledge to Action (KTA) framework, a two phased study will be undertaken. In Phase 1, the Delphi technique with stakeholder leaders will be used to review the current PUPCPG, identifying core strategies that are feasible to be adopted in Nigeria. These core strategies will become components of a PUP care bundle. In Phase 2, key stakeholder interviews will be used to identify the barriers, facilitators and potential implementation strategies to promote uptake of the PUP care bundle. A PUP care bundle, with three to eight components is expected to be developed from Phase 1. Implementation strategies to promote adoption of the PUP care bundle into clinical practice in selected Nigerian hospitals, is expected to result from Phase 2. Engagement of key stakeholders and consumers in the project should promote successful implementation and translate into better patient care. Using KTA, a knowledge translation framework, to guide the implementation of PUPCPG will enhance the likelihood of successful adoption in clinical practice. In implementing a PUP care bundle, developing countries face a number of challenges such as the feasibility of its components and the required resources.

Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study.

PubMed

Parsch, Cathrin S; Boonstra, Adrianne; Teubner, David; Emmerton, Wade; McKenny, Brian; Ellis, Daniel Y

2017-06-01

The aim of this study was to review mental health patients transported by a dedicated statewide critical care retrieval team before and after the implementation of a ketamine sedation guideline. This is a a retrospective cohort study of mental health patients with acute behavioural disturbance, transported between January 2010 and December 2015. A total of 78 patients were transported in the study period, 50 before and 28 after implementation of the ketamine guideline in June 2013. The introduction of the ketamine guideline was associated with a significant reduction in intubation for transport (36.00 vs 7.14%) (odds ratio 0.14, 95% confidence interval 0.02-0.71, P < 0.01). The likelihood of utilising ketamine for non-intubated patients (n = 58) was higher in the period after implementation (37.50 vs 84.62%, odds ratio 9.17, 95% confidence interval 2.54-33.08, P < 0.005). The incidence of complications in our series was low. The implementation of a ketamine clinical practice guideline for agitated mental health patients was associated with an increase in the number of patients receiving ketamine as part of their sedation regime and a reduction in the number of patients requiring intubation for transport. Appropriately trained critical care retrieval teams should consider ketamine as part of the sedation regime for agitated mental health patients. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Implementation of a guideline for low back pain management in primary care: a cost-effectiveness analysis.

PubMed

Becker, Annette; Held, Heiko; Redaelli, Marcus; Chenot, Jean F; Leonhardt, Corinna; Keller, Stefan; Baum, Erika; Pfingsten, Michael; Hildebrandt, Jan; Basler, Heinz-Dieter; Kochen, Michael M; Donner-Banzhoff, Norbert; Strauch, Konstantin

2012-04-15

Cost-effectiveness analysis alongside a cluster randomized controlled trial. To study the cost-effectiveness of 2 low back pain guideline implementation (GI) strategies. Several evidence-based guidelines on management of low back pain have been published. However, there is still no consensus on the effective implementation strategy. Especially studies on the economic impact of different implementation strategies are lacking. This analysis was performed alongside a cluster randomized controlled trial on the effectiveness of 2 GI strategies (physician education alone [GI] or physician education in combination with motivational counseling [MC] by practice nurses)--both compared with the postal dissemination of the guideline (control group, C). Sociodemographic data, pain characteristics, and cost data were collected by interview at baseline and after 6 and 12 months. low back pain-related health care costs were valued for 2004 from the societal perspective. For the cost analysis, 1322 patients from 126 general practices were included. Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls. In addition, both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data. Trends in cost-effectiveness are visible but need to be confirmed in future studies. Researchers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the randomization success by reviewing non-cost parameters like clinical data alone.

Improving the implementation of nutrition guidelines in childcare centres improves child dietary intake: findings of a randomised trial of an implementation intervention.

PubMed

Seward, Kirsty; Wolfenden, Luke; Finch, Meghan; Wiggers, John; Wyse, Rebecca; Jones, Jannah; Yoong, Sze Lin

2018-02-01

Evidence suggests that improvements to the childcare nutrition environment can have a positive impact on child dietary intake. The primary aim of the present study was to assess, relative to usual care, the effectiveness of a multi-strategy implementation intervention in improving childcare compliance with nutrition guidelines. As a secondary aim, the impact on child dietary intake was assessed. Parallel-group, randomised controlled trial design. The 6-month intervention was designed to overcome barriers to implementation of the nutrition guidelines that had been identified by applying the theoretical domains framework. Hunter New England region, New South Wales, Australia. Forty-five centre-based childcare services. There were no differences between groups in the proportion of services providing food servings (per child) compliant with nutrition guideline recommendations for all five (5/5) food groups at follow-up (i.e. full compliance). Relative to control services, intervention services were more likely to be compliant with guidelines (OR; 95 % CI) in provision of fruit (10·84; 1·19, 551·20; P=0·0024), meat and meat alternatives (8·83; 1·55, -; P=0·023), dairy (8·41; 1·60, 63·62; P=0·006) and discretionary foods (17·83; 2·15, 853·73; P=0·002). Children in intervention services consumed greater servings (adjusted difference; 95 % CI) of fruit (0·41; 0·09, 0·73; P=0·014) and vegetables (0·70; 0·33, 1·08; P<0·001). Findings indicate that service-level changes to menus in line with dietary guidelines can result in improvements to children's dietary intake. The study provides evidence to advance implementation research in the setting as a means of enhancing child public health nutrition.

Controlling corporate influence in health policy making? An assessment of the implementation of article 5.3 of the World Health Organization framework convention on tobacco control.

PubMed

Fooks, Gary Jonas; Smith, Julia; Lee, Kelley; Holden, Chris

2017-03-08

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) stands to significantly reduce tobacco-related mortality by accelerating the introduction of evidence-based tobacco control measures. However, the extent to which States Parties have implemented the Convention varies considerably. Article 5.3 of the FCTC, is intended to insulate policy-making from the tobacco industry's political influence, and aims to address barriers to strong implementation of the Convention associated with tobacco industry political activity. This paper quantitatively assesses implementation of Article 5.3's Guidelines for Implementation, evaluates the strength of Parties' efforts to implement specific recommendations, and explores how different approaches to implementation expose the policy process to continuing industry influence. We cross-referenced a broad range of documentary data (including FCTC Party reports and World Bank data on the governance of conflicts of interest in public administration) against Article 5.3 implementation guidelines (n = 24) for 155 Parties, and performed an in-depth thematic analysis to examine the strength of implementation for specific recommendations. Across all Parties, 16% of guideline recommendations reviewed have been implemented. Eighty-three percent of Parties that have taken some action under Article 5.3 have introduced less than a third of the guidelines. Most compliance with the guidelines is achieved through pre-existing policy instruments introduced independently of the FCTC, which rarely cover all relevant policy actors and fall short of the guideline recommendations. Measures introduced in response to the FCTC are typically restricted to health ministries and not explicit about third parties acting on behalf of the industry. Parties systematically overlook recommendations that facilitate industry monitoring. Highly selective and incomplete implementation of specific guideline recommendations facilitates extensive ongoing opportunities for industry policy influence. Stronger commitment to implementation is required to ensure consistently strong compliance with the FCTC internationally.

Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical practice.

PubMed

Saunders, Hannele

2015-07-01

To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar. Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context. A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline. A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland. Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery. A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes. © 2015 John Wiley & Sons Ltd.

Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document

PubMed Central

Pinnock, Hilary; Barwick, Melanie; Carpenter, Christopher R; Eldridge, Sandra; Grandes, Gonzalo; Griffiths, Chris J; Rycroft-Malone, Jo; Meissner, Paul; Murray, Elizabeth; Patel, Anita; Sheikh, Aziz; Taylor, Stephanie J C

2017-01-01

Objectives Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies. Methods An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts. Results The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice. Conclusions Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice. PMID:28373250

Antimicrobial stewardship: a qualitative study of the development of national guidelines for antibiotic use in hospitals.

PubMed

Feiring, Eli; Walter, Anne Berit

2017-11-21

As effective antibiotics are becoming a scarce resource, governmental regulation is needed to promote responsible use. Implementation of antibiotic stewardship and practice guidelines in health care facilities seems to be crucial to this effort. Empirical studies suggest, however, that guidelines have limited influence on health professionals' behavior and practice. Barriers and facilitators to guideline implementability are much studied, but little attention has been given to health professionals' perceptions of normative acceptability of guidelines as a condition for compliance. The aim of the present study was first, to examine if and how aspects potentially promoting acceptability and compliance among clinical target users were addressed during development of Norwegian national guidelines for antibiotic use in hospitals and second, to identify procedural characteristics of the development process that were perceived by target users to yield legitimate guidelines. Qualitative deductive thematic analysis was used. A theoretical framework inspired by the AGREE II Instrument and the Accountability for reasonableness framework assisted data gathering and interpretation. Archival data was collected and used to detail the guideline development process. Semi-structured, in-depth interviews with eight clinicians with extensive knowledge of the guidelines were carried out. Guideline development was characterized by i) broad agreement about scope and purpose, ii) broad involvement of stakeholders in the development process, iii) use of systematic methods to search for and apply evidence, iv) easily identifiable and specific recommendations, v) provision of tools on how to put recommendations into practice, and vi) editorial independence. Several procedural characteristics were perceived by the interviewees as promoting guideline legitimacy; i) diverse perspectives systematically involved in the process, ii) accessibility and transparency of the rationales for decision making, iii) opportunities for appeals and reconsiderations, and iv) regulative authority. This study provides insights as to how guidelines that are intended to promote responsible use of antibiotics in hospitals can be carefully developed to facilitate perceptions of relevance, transparency, and authority by health professionals.

What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review.

PubMed

Gotlib Conn, Lesley; Nathens, Avery B; Perrier, Laure; Haas, Barbara; Watamaniuk, Aaron; Daniel Pereira, Diego; Zwaiman, Ashley; da Luz, Luis Teodoro

2018-05-09

Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate. Results will be disseminated through scientific publication and conferences. CRD42018084273. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Performing Compliance: The Work of Local Policy Workers during the Implementation of National Health Promotion Guidelines

ERIC Educational Resources Information Center

Wimmelmann, Camila Lawaetz

2017-01-01

Guidelines are increasingly used to regulate how local authorities engage in practices. Focusing on the Danish national health promotion guidelines, this article reveals that the local policy workers did not implement the guidelines as proposed. Using a dramaturgical framework, it illustrates how the local policy workers front-staged some…

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators.

PubMed

Graham, Ian D; Logan, Jo; Davies, Barbara; Nimrod, Carl

2004-12-01

Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

The impact of the implementation of the postpartum haemorrhage management guidelines at the first regional perinatal centre in Southern Kazakhstan.

PubMed

Nadisauskiene, Ruta J; Dobozinskas, Paulius; Kacerauskiene, Justina; Kliucinskas, Mindaugas; Zhumagali, Ismailov; Kokenova, Madina; Bekeshov, Jesengeldy; Dzabagijeva, Saltanat; Sapargalijeva, Aigul; Glazebnaja, Inna; Konyrbajeva, Gulmyra; Uteshova, Zijas; Tasbulatova, Aina

2016-08-19

Postpartum haemorrhage (PPH) remains one of the most common causes of maternal morbidity and mortality. Therefore, clearly written PPH management guidelines should be used in clinical practice. The aim of this study was to evaluate the effectiveness of the implementation of PPH management guidelines at the First Regional Perinatal Centre of Southern Kazakhstan (FRPC). Between 2012 and 2013 an interventional study was performed whereby the PPH management guidelines were implemented at the FRPC. All of the deliveries that were complicated by PPH 8 months before and 8 months after the intervention were analysed. Prevalence and severity of PPH, and the change in prevention, diagnostics and management of PPH was evaluated and statistical analysis using the SPSS 22.0 was performed. There were in total 5404 and 5956 deliveries in the pre- and post-intervention periods, respectively. The rates of PPH and severe PPH decreased from 1.17 to 1.02 % (p = 0.94) and from 0.24 to 0.22 % (p = 0.94), respectively. Blood loss on average increased from 1055 to 1170 ml in the post-intervention period. The pharmacological treatment of postpartum haemorrhage with uterotonics was administered most frequently during both periods. After the implementation of the guidelines, the number of transfused units of packed red blood cells decreased from 4.76 to 2.48 units/case. In addition, the amount of transfused fresh frozen plasma decreased by 20 %. The number of conservative interventions and conservative operations increased from 7.9 to 52.7 % and from 3.9 to 48.6 %, respectively. The number of hysterectomies decreased from 23.7 % in pre-intervention to 8.1 % in the post-intervention period. The implementation of the PPH management guidelines had a positive effect on PPH prevention, diagnostics and management. It led to a more conservative aproach to the treatment of PPH. Therefore, clearly written PPH management guidelines, adapted for a particular hospital, should be developed and used in clinical practice.

Experience of adapting and implementing an evidence-based nursing guideline for prevention of diaper dermatitis in a paediatric oncology setting.

PubMed

Espirito Santo, Anelise; Choquette, Anne

2013-06-01

Diaper dermatitis is one of the most common skin problems in children often caused by irritants that promote skin breakdown, such as moisture and faecal enzymes. It has been estimated that the incidence of diaper dermatitis is as high as 50% in children receiving chemotherapy. The scientific literature suggests a variety of preventative measures, but only a minority are systematically tested and supported by clinical evidence. The purpose of this paper is to adapt and implement a skincare guideline to better prevent diaper dermatitis in the paediatric oncology population. The Knowledge to Action process was used to guide the adaptation and implementation of the new guideline. As part of this process, different tools were used to identify and review selected knowledge (Appraisal of Guidelines Research Evaluation instrument), to tailor and adapt knowledge to the local context (ADAPTE process), to implement interventions (Registered Nurses' Association of Ontario toolkit) and to evaluate outcomes (qualitative analysis). The main outcomes measured included implementation of the guideline and nursing practice change. The guideline was successfully implemented as reported by nurses in focus group sessions and as measured by changes in nursing documentation. The implementation of the guideline was successful on the account of the interplay of three core elements: The level and nature of the evidence; the context in which the research was placed; the method in which the process was facilitated. © 2013 The Authors. International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute.

Assessing the cost of implementing the 2011 Society of Obstetricians and Gynecologists of Canada and Canadian College of Medical Genetics practice guidelines on the detection of fetal aneuploidies.

PubMed

Lilley, Margaret; Hume, Stacey; Karpoff, Nina; Maire, Georges; Taylor, Sherry; Tomaszewski, Robert; Yoshimoto, Maisa; Christian, Susan

2017-09-01

The Society of Obstetricians and Gynecologists of Canada and the Canadian College of Medical Genetics published guidelines, in 2011, recommending replacement of karyotype with quantitative fluorescent polymerase chain reaction when prenatal testing is performed because of an increased risk of a common aneuploidy. This study's objective is to perform a cost analysis following the implementation of quantitative fluorescent polymerase chain reaction as a stand-alone test. A total of 658 samples were received between 1 April 2014 and 31 August 2015: 576 amniocentesis samples and 82 chorionic villi sampling. A chromosome abnormality was identified in 14% (93/658) of the prenatal samples tested. The implementation of the 2011 Society of Obstetricians and Gynecologists of Canada and the Canadian College of Medical Genetics guidelines in Edmonton and Northern Alberta resulted in a cost savings of $46 295.80. The replacement of karyotype with chromosomal microarray for some indications would be associated with additional costs. The implementation of new test methods may provide cost savings or added costs. Cost analysis is important to consider during the implementation of new guidelines or technologies. © 2017 John Wiley & Sons, Ltd. © 2017 John Wiley & Sons, Ltd.

Proper management of rheumatoid arthritis in Latin America. What the guidelines say?

PubMed

Brenol, Claiton V; Nava, Jorge Ivan Gamez; Soriano, Enrique R

2015-03-01

To analyze characteristics of clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) developed in Latin American (LA) countries and to describe the knowledge, use, and barriers for their implementation perceived among LA rheumatologists, a comprehensive literature search including Medline, PubMed, Cochrane Library, LILACS and Scielo was performed. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied for evaluation. A survey was sent to PANLAR members containing questions related to knowledge about guidelines, application of the recommendations, and difficulties in implementing CPGs. Eight guidelines were identified. Most guidelines were evidence based (62 %), but in only 37 % a systematic literature search was done. None of the guidelines included patients' views and preferences, and only few of them stated an updating procedure. Funding body independence and disclosure of conflicts of interest were rarely reported. The survey was answered by 214 rheumatologists from all Latin American countries. Most rheumatologist reported knowledge and use of clinical guidelines, mainly international ones. In general, rheumatologist felt that guidelines apply to only a minority of patients seen in daily clinical practice. Limited access expensive drugs, suggested by the guidelines, was the most frequent barrier to guidelines implementation that was reported. A good number of guidelines on the treatment of rheumatoid arthritis have been developed in Latin America. Most of them are lacking some of the components recognized for high-quality clinical guidelines development. In spite that most rheumatologist know and apply guidelines, access to drugs is still a very important barrier to their implementation in Latin America.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

PubMed Central

2014-01-01

Background The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED. Methods We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. Results The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED. Conclusions There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. Trial registration ClinicalTrials.gov registration number NCT00756704 PMID:24460974

Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration.

PubMed

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-06-01

The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care.

Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa.

PubMed Central

Deen, Jacqueline L.; Funk, Matthias; Guevara, Victor C.; Saloojee, Haroon; Doe, James Y.; Palmer, Ayo; Weber, Martin W.

2003-01-01

OBJECTIVE: To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. METHODS: A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. FINDINGS: Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. CONCLUSION: Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality. PMID:12764489

Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa.

PubMed

Deen, Jacqueline L; Funk, Matthias; Guevara, Victor C; Saloojee, Haroon; Doe, James Y; Palmer, Ayo; Weber, Martin W

2003-01-01

To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality.

Towards Design Guidelines for Work Related Learning Arrangements

ERIC Educational Resources Information Center

Lappia, Josephine H.

2011-01-01

Purpose: The purpose of the study is to produce design guidelines based on insights from both practice and theory that will enable teachers and educational developers to execute the design, implementation and evaluation of their work-related learning arrangements with stakeholders involved. Design/methodology/approach: The first study reported in…

Implementation of the American College of Cardiology/American Heart Association 2008 Guidelines for the Management of Adults With Congenital Heart Disease.

PubMed

Goossens, Eva; Fernandes, Susan M; Landzberg, Michael J; Moons, Philip

2015-08-01

Although different guidelines on adult congenital heart disease (ACHD) care advocate for lifetime cardiac follow-up, a critical appraisal of the guideline implementation is lacking. We investigated the implementation of the American College of Cardiology/American Heart Association 2008 guidelines for ACHD follow-up by investigating the type of health care professional, care setting, and frequency of outpatient visits in young adults with CHD. Furthermore, correlates for care in line with the recommendations or untraceability were investigated. A cross-sectional observational study was conducted, including 306 patients with CHD who had a documented outpatient visit at pediatric cardiology before age 18 years. In all, 210 patients (68.6%) were in cardiac follow-up; 20 (6.5%) withdrew from follow-up and 76 (24.9%) were untraceable. Overall, 198 patients were followed up in tertiary care, 1/4 (n = 52) of which were seen at a formalized ACHD care program and 3/4 (n = 146) remained at pediatric cardiology. Of those followed in formalized ACHD and pediatric cardiology care, the recommended frequency was implemented in 94.2% and 89%, respectively (p = 0.412). No predictors for the implementation of the guidelines were identified. Risk factors for becoming untraceable were none or lower number of heart surgeries, health insurance issues, and nonwhite ethnicity. In conclusion, a significant number of adults continue to be cared for by pediatric cardiologists, indicating that transfer to adult-oriented care was not standard practice. Frequency of follow-up for most patients was in line with the ACC/AHA 2008 guidelines. A considerable proportion of young adults were untraceable in the system, which makes them vulnerable for discontinuation of care. Copyright © 2015 Elsevier Inc. All rights reserved.

Health Economic Evaluation of a Strict Glucose Control Guideline Implemented Using Point-of-Care Testing in Three Intensive Care Units in The Netherlands.

PubMed

van Hooijdonk, Roosmarijn T M; Steuten, Lotte M G; Kip, Michelle M A; Monteban, Helma; Mulder, Marianne R; van Braam Houckgeest, Floris; van der Sluijs, Johannes P; Abu-Hanna, Ameen; Spronk, Peter E; Schultz, Marcus J

2015-08-01

Point-of-care testing of blood glucose (BG-POCT) is essential for safe and effective insulin titrations in critically ill patients under glucose control with insulin. The costs associated with this practice are considered substantial, especially when more frequent blood glucose (BG) testing is needed, as with more strict glucose control (SGC) aiming for lower BG levels. The objective of this study was to estimate, from a hospital perspective, the incremental cost effectiveness of an SGC guideline, aiming for BG levels of 4.4-6.1 mmol/L, compared to the situation before implementation of that guideline (aiming for BG levels <8.3 mmol/L), both using BG-POCT. This is a secondary analysis of a guideline implementation project aiming for implementation of a guideline of SGC in three intensive care units in The Netherlands. A Markov model including the four health states 'target glucose', 'hyperglycaemia' (defined as BG levels >6.1 mmol/L), 'hypoglycaemia' (defined as BG levels <4.4 mmol/L) and 'in-hospital death' was developed to compare expected costs, number of patients within target and number of life-years saved before and after implementation of the SGC guideline. The effectiveness estimates are based on empirical data from 3195 patients 12 and 24 months before and after implementation of the guideline, respectively. All costs have been converted to price year 2013, and are estimated based on hospital data, the literature and available price lists. The number of BG-POCT increased from 4.8 [interquartile range (IQR) 2.6-6.7] to 8.0 [IQR 4.1-11.2] per patient per day, accruing 58% higher costs for BG-POCT (€13.56 vs. €8.57 per patient) in the SGC protocol versus the situation before implementation. When taking total hospital costs and clinical effects into account, implementation of the SGC guideline increased total hospital costs per patient by 1.8%, i.e., €355 (from €20,617 to €20,972) during the inpatient stay, while the number of patients in target glucose levels increased by 1.4% (i.e., from 881 to 895 per 1000 patients). This translates to an incremental cost-effectiveness ratio of €25 per additional patient within the target glucose level. The model outcomes are most sensitive to changes in ICU length of stay. The increase in the number of patients and time within target glucose levels is achieved with a small increase in total direct hospital costs.

Food Service Perspectives on National School Lunch Program Implementation.

PubMed

Tabak, Rachel G; Moreland-Russell, Sarah

2015-09-01

Explore barriers and facilitators to implementation of the new National School Lunch Program (NSLP) policy guidelines. Interviews with eight food service directors using an interview guide informed by the Consolidated Framework for Implementation Research. Food service personnel; parents, teachers, school staff; and students were important stakeholders. Characteristics of the new NSLP policy guidelines were reported to create increased demands; resources alleviated some barriers. Directors reported increased food and labor costs, food sourcing challenges, decreased student participation, and organizational constraints as barriers to implementation. Creativity in menu planning facilitated success. Factors within the food service department, characteristics of implementing individuals and the new NSLP policy guidelines, and stakeholder involvement in the implementation process relate to successful implementation.

Non-vitamin K antagonist oral anticoagulants and atrial fibrillation guidelines in practice: barriers to and strategies for optimal implementation.

PubMed

Camm, A John; Pinto, Fausto J; Hankey, Graeme J; Andreotti, Felicita; Hobbs, F D Richard

2015-07-01

Stroke is a leading cause of morbidity and mortality worldwide. Atrial fibrillation (AF) is an independent risk factor for stroke, increasing the risk five-fold. Strokes in patients with AF are more likely than other embolic strokes to be fatal or cause severe disability and are associated with higher healthcare costs, but they are also preventable. Current guidelines recommend that all patients with AF who are at risk of stroke should receive anticoagulation. However, despite this guidance, registry data indicate that anticoagulation is still widely underused. With a focus on the 2012 update of the European Society of Cardiology (ESC) guidelines for the management of AF, the Action for Stroke Prevention alliance writing group have identified key reasons for the suboptimal implementation of the guidelines at a global, regional, and local level, with an emphasis on access restrictions to guideline-recommended therapies. Following identification of these barriers, the group has developed an expert consensus on strategies to augment the implementation of current guidelines, including practical, educational, and access-related measures. The potential impact of healthcare quality measures for stroke prevention on guideline implementation is also explored. By providing practical guidance on how to improve implementation of the ESC guidelines, or region-specific modifications of these guidelines, the aim is to reduce the potentially devastating impact that stroke can have on patients, their families and their carers. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.

Implementation strategies: recommendations for specifying and reporting

PubMed Central

2013-01-01

Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies. PMID:24289295

Implementation strategies: recommendations for specifying and reporting.

PubMed

Proctor, Enola K; Powell, Byron J; McMillen, J Curtis

2013-12-01

Implementation strategies have unparalleled importance in implementation science, as they constitute the 'how to' component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of 'packaged' approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and 'reproducibility.' We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

Management of venous thromboembolism in cancer patients according to guidelines after educative measures.

PubMed

Pillet, Armelle; Minne, Floriane; Belhadj Chaidi, Rafik; Chapelle, Gilles; Ferru, Aurélie

2018-05-01

Guidelines for venous thromboembolism treatment with curative anticoagulation in cancer patients are poorly respected. Yet, venous thromboembolism is the second leading cause of death in cancer patients, after cancer progression. The aim of this study was to re-evaluate the application of these guidelines after the implementation of educational measures for patients and caregivers, and also to assess the acceptability and tolerance of treatment by patients. On the one hand, a prospective observational study conducted in cancer patients with VTE allowed to assess the rate of compliance to guidelines. These phone calls with patients also provided information on their perception of their treatment. On the other hand, surveys were sent to healthcare professionals before and after educative actions took place (information meetings and information sheets distribution) in order to evaluate the evolution of their knowledge about guidelines. Among the 110 patients included in the study, 71.8% received treatment according to guidelines: choice of the anticoagulant (low-molecular-weight heparin or antivitamin K if contraindicated) and right period of treatment. Among the patients, 84.1% were willing to continue treatment beyond 6 months. Healthcare professionals' knowledge about guidelines has increased significantly (from 20% to 42%) following the information meetings and information sheets distribution. These educative actions seem to have a positive impact on knowledge of the recommendations and their implementation. Copyright © 2018. Published by Elsevier Masson SAS.

Disability Policy Implementation from a Cross-Cultural Perspective

ERIC Educational Resources Information Center

Verdugo, Miguel A.; Jenaro, Cristina; Calvo, Isabel; Navas, Patricia

2017-01-01

Implementation of disability policy is influenced by social, political, and cultural factors. Based on published work, this article discusses four guidelines considered critical for successful policy implementation from a cross-cultural perspective. These guidelines are to: (a) base policy implementation on a contextual analysis, (b) employ a…

Guidelines for the Gamification of Self-Management of Chronic Illnesses: Multimethod Study

PubMed Central

Wills, Gary; Ranchhod, Ashok

2017-01-01

Background Gamification is the use of game elements and techniques in nongaming contexts. The use of gamification in health care is receiving a great deal of attention in both academic research and the industry. However, it can be noticed that many gamification apps in health care do not follow any standardized guidelines. Objective This research aims to (1) present a set of guidelines based on the validated framework the Wheel of Sukr and (2) assess the guidelines through expert interviews and focus group sessions with developers. Methods Expert interviews (N=6) were conducted to assess the content of the guidelines and that they reflect the Wheel of Sukr. In addition, the guidelines were assessed by developers (N=15) in 5 focus group sessions, where each group had an average of 3 developers. Results The guidelines received support from the experts. By the end of the sixth interview, it was determined that a saturation point was reached. Experts agreed that the guidelines accurately reflect the framework the Wheel of Sukr and that developers can potentially use them to create gamified self-management apps for chronic illnesses. Moreover, the guidelines were welcomed by developers who participated in the focus group sessions. They found the guidelines to be clear, useful, and implementable. Also, they were able to suggest many ways of gamifying a nongamified self-management app when they were presented with one. Conclusions The findings suggest that the guidelines introduced in this research are clear, useful, and ready to be implemented for the creation of self-management apps that use the notion of gamification as described in the Wheel of Sukr framework. The guidelines are now ready to be practically tested. Further practical studies of the effectiveness of each element in the guidelines are to be carried out. PMID:28500018

Pressure ulcer guideline development and dissemination in Europe.

PubMed

Meesterberends, Esther; Halfens, Ruud; Lohrmann, Christa; de Wit, Rianne

2010-06-01

To explore the current state of pressure ulcer guideline development and dissemination, from national to local level (i.e. nursing homes) in six European countries: England, Germany, Italy, the Netherlands, Portugal and Sweden. Pressure ulcers are a persistent problem in healthcare institutions. Their prevalence is influenced by many factors, one of them being the development and dissemination of pressure ulcer guidelines. These are difficult and complex processes and it is not clear whether they differ between European countries. Literature review and semi-structured interviews. Interviews were conducted in six countries at national and nursing home level. Four countries had national pressure ulcer prevention and treatment guidelines. Portugal had no national guidelines and Sweden had shifted the responsibility to regional level. All participating nursing homes had pressure ulcer guidelines except those in Portugal. Control and monitoring of guideline dissemination was carried out only in Sweden and England. All countries studied have national or regional pressure ulcer prevention and treatment guidelines, except Portugal. Portugal is also the only country where none of the nursing homes included had pressure ulcer guidelines. Because the dissemination of such guidelines does not imply actual implementation, further research should focus on the implementation process. Clinical guidelines, like pressure ulcer guidelines, are important tools in guiding the care processes in healthcare institutions. Successful dissemination of guidelines from national level to individual healthcare institutions is a first and necessary step in actually applying them. Monitoring of the guideline dissemination process is therefore essential.

Perceived barriers to and facilitators of the implementation of priority clinical preventive services guidelines.

PubMed

Ayres, Cynthia G; Griffith, Hurdis M

2007-03-01

To obtain feedback from contracted health plan (HP) clinicians responsible for implementing preventive services regarding an established set of priority guidelines identified by a coalition of medical directors and to identify barriers to and facilitators of the implementation of these priority guidelines in clinician practice. Qualitative design using a focus group approach. Three focus group meetings among contracted HP clinicians were conducted in New Jersey in 3 geographic regions (northern, central, and southern New Jersey). Clinicians directly involved in delivering preventive services to pediatric, adult, and geriatric patients participated. Barriers to guideline implementation were identified by the clinicians regarding payment and cost, time, legal issues, inconsistency among HP tools, tracking, a lack of internalization, and the patient-clinician relationship. In addition, facilitators of guideline implementation, including HP support, patient materials, clinician awareness, and tool consistency, were identified. Clinicians' perceived barriers to guideline implementation are in themselves a barrier to the delivery of preventive care services. If clinicians perceive barriers to implementing priority recommendations, they may be unlikely to make the conscious effort to deliver preventive care. There needs to be better dialogue between HPs and contracted clinicians to minimize the perceptions of barriers and to increase clinician awareness of and sensitivity to preventive care for priority implementation. To improve the delivery of preventive services in clinician practice, competing HPs must communicate in a single voice with contracted clinicians in the area of preventive care.

The CARE guidelines: consensus-based clinical case report guideline development.

PubMed

Gagnier, Joel J; Kienle, Gunver; Altman, Douglas G; Moher, David; Sox, Harold; Riley, David

2014-01-01

A case report is a narrative that describes, for medical, scientific, or educational purposes, a medical problem experienced by one or more patients. Case reports written without guidance from reporting standards are insufficiently rigorous to guide clinical practice or to inform clinical study design. Develop, disseminate, and implement systematic reporting guidelines for case reports. We used a three-phase consensus process consisting of (1) pre-meeting literature review and interviews to generate items for the reporting guidelines, (2) a face-to-face consensus meeting to draft the reporting guidelines, and (3) post-meeting feedback, review, and pilot testing, followed by finalization of the case report guidelines. This consensus process involved 27 participants and resulted in a 13-item checklist-a reporting guideline for case reports. The primary items of the checklist are title, key words, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, therapeutic interventions, follow-up and outcomes, discussion, patient perspective, and informed consent. We believe the implementation of the CARE (CAse REport) guidelines by medical journals will improve the completeness and transparency of published case reports and that the systematic aggregation of information from case reports will inform clinical study design, provide early signals of effectiveness and harms, and improve healthcare delivery. Copyright © 2014 Reproduced with permission of Global Advances in Health and Medicine. Published by Elsevier Inc. All rights reserved.

Developing standards for reporting implementation studies of complex interventions (StaRI): a systematic review and e-Delphi.

PubMed

Pinnock, Hilary; Epiphaniou, Eleni; Sheikh, Aziz; Griffiths, Chris; Eldridge, Sandra; Craig, Peter; Taylor, Stephanie J C

2015-03-30

Dissemination and implementation of health care interventions are currently hampered by the variable quality of reporting of implementation research. Reporting of other study types has been improved by the introduction of reporting standards (e.g. CONSORT). We are therefore developing guidelines for reporting implementation studies (StaRI). Using established methodology for developing health research reporting guidelines, we systematically reviewed the literature to generate items for a checklist of reporting standards. We then recruited an international, multidisciplinary panel for an e-Delphi consensus-building exercise which comprised an initial open round to revise/suggest a list of potential items for scoring in the subsequent two scoring rounds (scale 1 to 9). Consensus was defined a priori as 80% agreement with the priority scores of 7, 8, or 9. We identified eight papers from the literature review from which we derived 36 potential items. We recruited 23 experts to the e-Delphi panel. Open round comments resulted in revisions, and 47 items went forward to the scoring rounds. Thirty-five items achieved consensus: 19 achieved 100% agreement. Prioritised items addressed the need to: provide an evidence-based justification for implementation; describe the setting, professional/service requirements, eligible population and intervention in detail; measure process and clinical outcomes at population level (using routine data); report impact on health care resources; describe local adaptations to the implementation strategy and describe barriers/facilitators. Over-arching themes from the free-text comments included balancing the need for detailed descriptions of interventions with publishing constraints, addressing the dual aims of reporting on the process of implementation and effectiveness of the intervention and monitoring fidelity to an intervention whilst encouraging adaptation to suit diverse local contexts. We have identified priority items for reporting implementation studies and key issues for further discussion. An international, multidisciplinary workshop, where participants will debate the issues raised, clarify specific items and develop StaRI standards that fit within the suite of EQUATOR reporting guidelines, is planned. The protocol is registered with Equator: http://www.equator-network.org/library/reporting-guidelines-under-development/#17 .

Guidelines for reporting evaluations based on observational methodology.

PubMed

Portell, Mariona; Anguera, M Teresa; Chacón-Moscoso, Salvador; Sanduvete-Chaves, Susana

2015-01-01

Observational methodology is one of the most suitable research designs for evaluating fidelity of implementation, especially in complex interventions. However, the conduct and reporting of observational studies is hampered by the absence of specific guidelines, such as those that exist for other evaluation designs. This lack of specific guidance poses a threat to the quality and transparency of these studies and also constitutes a considerable publication hurdle. The aim of this study thus was to draw up a set of proposed guidelines for reporting evaluations based on observational methodology. The guidelines were developed by triangulating three sources of information: observational studies performed in different fields by experts in observational methodology, reporting guidelines for general studies and studies with similar designs to observational studies, and proposals from experts in observational methodology at scientific meetings. We produced a list of guidelines grouped into three domains: intervention and expected outcomes, methods, and results. The result is a useful, carefully crafted set of simple guidelines for conducting and reporting observational studies in the field of program evaluation.

Manned space flight nuclear system safety. Volume 5: Nuclear System safety guidelines. Part 1: Space base nuclear safety

NASA Technical Reports Server (NTRS)

1972-01-01

The design and operations guidelines and requirements developed in the study of space base nuclear system safety are presented. Guidelines and requirements are presented for the space base subsystems, nuclear hardware (reactor, isotope sources, dynamic generator equipment), experiments, interfacing vehicles, ground support systems, range safety and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

Manned space flight nuclear system safety. Voluem 5: Nuclear system safety guidelines. Part 2: Space shuttle/nuclear payloads safety

NASA Technical Reports Server (NTRS)

1972-01-01

The design and operations guidelines and requirements developed in the study of space shuttle nuclear system transportation are presented. Guidelines and requirements are presented for the shuttle, nuclear payloads (reactor, isotope-Brayton and small isotope sources), ground support systems and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol.

PubMed

Staveski, Sandra L; Wu, May; Tesoro, Tiffany M; Roth, Stephen J; Cisco, Michael J

2017-06-01

Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team. ©2017 American Association of Critical-Care Nurses.

Study protocol of an economic evaluation of an extended implementation strategy for the treatment of low back pain in general practice: a cluster randomised controlled trial.

PubMed

Jensen, Cathrine Elgaard; Riis, Allan; Pedersen, Kjeld Møller; Jensen, Martin Bach; Petersen, Karin Dam

2014-10-08

In Denmark, guidelines on low back pain management are currently being implemented; in association with this, a clinical trial is conducted. A health economic evaluation is carried out alongside the clinical trial to assess the cost-effectiveness of an extended implementation strategy to increase the general practitioners' adherence to the guidelines. In addition to usual dissemination, the extended implementation strategy is composed of visits from a guideline facilitator, stratification tools, and feedback on guideline adherence. The aim of this paper is to provide the considerations on the design of the health economic evaluation. The economic evaluation is carried out alongside a cluster randomised controlled trial consisting of 60 general practices in the North Denmark Region. An expected 1,200 patients between the age of 18 and 65 years with a low back pain diagnosis will be enrolled. The economic evaluation comprises both a cost-effectiveness analyses and a cost-utility analysis. Effectiveness measures include referral to secondary care, health-related quality of life measured by EQ-5D-5L, and disability measured by the Roland Morris disability questionnaire. Cost measures include all relevant additional costs of the extended implementation strategy compared to usual implementation. The economic evaluation will be performed from both a societal perspective and a health sector perspective with a 12-month time horizon. It is expected that the extended implementation strategy will reduce the number of patients referred to secondary care. It is hypothesised that the additional upfront cost of extended implementation will be counterbalanced by improvements in clinical practice and patient-related outcomes, thereby rendering the extended implementation strategy cost-effective. ClinicalTrials.gov: NCT01699256.

The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice.

PubMed

Breimaier, Helga E; Heckemann, Birgit; Halfens, Ruud J G; Lohrmann, Christa

2015-01-01

Implementing clinical practice guidelines (CPGs) in healthcare settings is a complex intervention involving both independent and interdependent components. Although the Consolidated Framework for Implementation Research (CFIR) has never been evaluated in a practical context, it appeared to be a suitable theoretical framework to guide an implementation process. The aim of this study was to evaluate the comprehensiveness, applicability and usefulness of the CFIR in the implementation of a fall-prevention CPG in nursing practice to improve patient care in an Austrian university teaching hospital setting. The evaluation of the CFIR was based on (1) team-meeting minutes, (2) the main investigator's research diary, containing a record of a before-and-after, mixed-methods study design embedded in a participatory action research (PAR) approach for guideline implementation, and (3) an analysis of qualitative and quantitative data collected from graduate and assistant nurses in two Austrian university teaching hospital departments. The CFIR was used to organise data per and across time point(s) and assess their influence on the implementation process, resulting in implementation and service outcomes. Overall, the CFIR could be demonstrated to be a comprehensive framework for the implementation of a guideline into a hospital-based nursing practice. However, the CFIR did not account for some crucial factors during the planning phase of an implementation process, such as consideration of stakeholder aims and wishes/needs when implementing an innovation, pre-established measures related to the intended innovation and pre-established strategies for implementing an innovation. For the CFIR constructs reflecting & evaluating and engaging, a more specific definition is recommended. The framework and its supplements could easily be used by researchers, and their scope was appropriate for the complexity of a prospective CPG-implementation project. The CFIR facilitated qualitative data analysis and provided a structure that allowed project results to be organised and viewed in a broader context to explain the main findings. The CFIR was a valuable and helpful framework for (1) the assessment of the baseline, process and final state of the implementation process and influential factors, (2) the content analysis of qualitative data collected throughout the implementation process, and (3) explaining the main findings.

Chronic kidney disease guideline implementation in primary care: a qualitative report from the TRANSLATE CKD study

PubMed Central

Vest, Bonnie M.; York, Trevor R.M.; Sand, Jessica; Fox, Chester H.; Kahn, Linda S.

2016-01-01

Background Primary care physicians (PCPs) are optimally situated to identify and manage early-stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national mixed-methods cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. Methods As part of mixed-methods process evaluation, semi-structured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the four domains of Normalization Process Theory (NPT). Results Identified themes illuminated the complex work undertaken in primary care practices to manage CKD. Barriers to guideline implementation were identified in each of the four NPT domains, including: 1) lack of knowledge and understanding around CKD (coherence), 2) difficulties engaging providers and patients in CKD management (cognitive participation), 3) limited time and competing demands (collective action), and 4) challenges obtaining and utilizing data to monitor progress (reflexive monitoring). Conclusions Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. PMID:26355134

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study.

PubMed

Vest, Bonnie M; York, Trevor R M; Sand, Jessica; Fox, Chester H; Kahn, Linda S

2015-01-01

Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. © Copyright 2015 by the American Board of Family Medicine.

Assessing implementation difficulties in tobacco use prevention and cessation counselling among dental providers.

PubMed

Amemori, Masamitsu; Michie, Susan; Korhonen, Tellervo; Murtomaa, Heikki; Kinnunen, Taru H

2011-05-26

Tobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains. A 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature. Internal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, α = 0.86), capability (13.3% of variance, α = 0.83), and opportunity (10.0% of variance, α = 0.71). This study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions.

Implementation of European standards of care for cystic fibrosis--control and treatment of infection.

PubMed

Elborn, J S; Hodson, M; Bertram, C

2009-05-01

Several guidelines on infection control and treatment of infection exist for cystic fibrosis (CF) caregivers, although the extent of implementation is variable. Adherence to European Consensus Guidelines for CF was studied by sending surveys to named healthcare professionals in 487 European CF centres/units. Qualitative data analysis was performed. A total of 177/547 (32%) surveys were returned. Infection control policies were implemented by most (77%) respondents. Separation of patients with Burkholderia cepacia was more common in adults (95%) than children (9%), and was implemented by 53% of respondents for Pseudomonas aeruginosa. Nebulised colistin plus oral ciprofloxacin was the most common (43%) therapy for P. aeruginosa infection. First infections of P. aeruginosa were usually treated with inhaled tobramycin; 41% of repondents did not intervene until lung function deteriorated. Most exacerbations were treated for less than the recommended period. European Consensus Guidelines are widely adhered to. Areas for improvement include: initiating therapy for exacerbations early, separating infected patients and optimising duration of antibiotic therapy.

The advantages and limitations of guideline adaptation frameworks.

PubMed

Wang, Zhicheng; Norris, Susan L; Bero, Lisa

2018-05-29

The implementation of evidence-based guidelines can improve clinical and public health outcomes by helping health professionals practice in the most effective manner, as well as assisting policy-makers in designing optimal programs. Adaptation of a guideline to suit the context in which it is intended to be applied can be a key step in the implementation process. Without taking the local context into account, certain interventions recommended in evidence-based guidelines may be infeasible under local conditions. Guideline adaptation frameworks provide a systematic way of approaching adaptation, and their use may increase transparency, methodological rigor, and the quality of the adapted guideline. This paper presents a number of adaptation frameworks that are currently available. We aim to compare the advantages and limitations of their processes, methods, and resource implications. These insights into adaptation frameworks can inform the future development of guidelines and systematic methods to optimize their adaptation. Recent adaptation frameworks show an evolution from adapting entire existing guidelines, to adapting specific recommendations extracted from an existing guideline, to constructing evidence tables for each recommendation that needs to be adapted. This is a move towards more recommendation-focused, context-specific processes and considerations. There are still many gaps in knowledge about guideline adaptation. Most of the frameworks reviewed lack any evaluation of the adaptation process and outcomes, including user satisfaction and resources expended. The validity, usability, and health impact of guidelines developed via an adaptation process have not been studied. Lastly, adaptation frameworks have not been evaluated for use in low-income countries. Despite the limitations in frameworks, a more systematic approach to adaptation based on a framework is valuable, as it helps to ensure that the recommendations stay true to the evidence while taking local needs into account. The utilization of frameworks in the guideline implementation process can be optimized by increasing the understanding and upfront estimation of resource and time needed, capacity building in adaptation methods, and increasing the adaptability of the source recommendation document.

Food Service Perspectives on National School Lunch Program Implementation

PubMed Central

Tabak, Rachel G.; Moreland-Russell, Sarah

2015-01-01

Objectives Explore barriers and facilitators to implementation of the new National School Lunch Program (NSLP) policy guidelines. Methods Interviews with eight food service directors using an interview guide informed by the Consolidated Framework for Implementation Research. Results Food service personnel; parents, teachers, school staff; and students were important stakeholders. Characteristics of the new NSLP policy guidelines were reported to create increased demands; resources alleviated some barriers. Directors reported increased food and labor costs, food sourcing challenges, decreased student participation, and organizational constraints as barriers to implementation. Creativity in menu planning facilitated success. Conclusions Factors within the food service department, characteristics of implementing individuals and the new NSLP policy guidelines, and stakeholder involvement in the implementation process relate to successful implementation. PMID:26417607

Critical attitudes and beliefs towards guidelines amongst palliative care professionals - results from a national survey.

PubMed

Kalies, Helen; Schöttmer, Rieke; Simon, Steffen T; Voltz, Raymond; Crispin, Alexander; Bausewein, Claudia

2017-03-21

Little is known about palliative care professionals' attitudes towards guidelines. In 2015, the German Association for Palliative Medicine (DGP) published an evidence based guideline for palliative care in adults with incurable cancer. Before publication we conducted a national survey among members of the DGP to detect possible barriers and facilitators for its implementation. The aim of the present publication was to evaluate critical attitudes and beliefs which could hinder the effective implementation of the new guideline and to evaluate differences within professional groups and medical specialisations. This web-based online survey was addressed to all members of the DGP in summer 2014. Twenty-one questions concerning attitudes and beliefs towards guidelines were a priori developed to represent the following topics: scepticism regarding the quality of guidelines, doubts about the implementation of guidelines, restrictions in treatment options through guidelines, discrepancy between palliative care values and guidelines. Differences within professions and specialisations were tested using Kruskal-Wallis tests. All 4.786 members with known email address were invited, 1.181 followed the link, 1.138 began to answer the questionnaire and 1.031 completed the questionnaire. More than half of participating members were physicians and one third nurses. Scepticism regarding the quality of existing guidelines was high (range 12.8-73.2%). Doubts regarding practical aspects of guidelines were less prevalent but still high (range 21.8-57.6%). About one third (range 5.4-31.4%) think that guidelines restrict their treatment options. In addition, 38.8% believed that guidelines are a kind of cookbook and restrict the flexibility of individual patient care. The majority saw no or little discrepancy between palliative care values and guidelines (range 68.4-82.6%). There were relatively small but significant differences between professions and specialisations. The person-centred and individual approach of palliative care does not seem to contradict the acceptance of guidelines. Main barriers were related to scepticism regarding the quality of guidelines and the implementation of guidelines in general.

Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias: Implementation of guidelines.

PubMed

Yang, H; Heidendael, J F; de Groot, J R; Konings, T C; Veen, G; van Dijk, A P J; Meijboom, F J; Sieswerda, G Tj; Post, M C; Winter, M M; Mulder, B J M; Bouma, B J

2018-04-15

Current guidelines on oral anticoagulation (OAC) in adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) consist of heterogeneous and divergent recommendations with limited level of evidence, possibly leading to diverse OAC management and different outcomes. Therefore, we aimed to evaluate real-world implementation and outcome of three guidelines on OAC management in ACHD patients with AA. The ESC GUCH 2010, PACES/HRS 2014 and ESC atrial fibrillation (AF) 2016 guidelines were assessed for implementation. ACHD patients with recurrent or sustained non-valvular AA from 5 tertiary centers were identified using a national ACHD registry. After two years of prospective follow-up, thromboembolism, major bleeding and death were assessed. In total, 225 adults (mean age 54±15years, 55% male) with various defects (simple 43%; moderate 37%; complex 20%) and AA were included. Following the most strict indication (OAC is recommended in all three guidelines), one should treat a mere 37% of ACHD patients with AA, whereas following the least strict indication (OAC is recommended in any one of the three guidelines), one should treat 98% of patients. The various guidelines were implemented in 54-80% of patients. From all recommendations, Fontan circulation, CHA2DS2-VASc≥1 and AF were independently associated with OAC prescription. Superiority of any guideline in identifying outcome (n=15) could not be demonstrated. The implementation of current guidelines on OAC management in ACHD patients with AA is low, probably due to substantial heterogeneity among guidelines. OAC prescription in daily practice was most consistent in patients with AF and CHA2DS2-VASc≥1 or Fontan circulation. Copyright © 2017 Elsevier B.V. All rights reserved.

Implementation of national practice guidelines to reduce waste and optimize patient value.

PubMed

Langell, John T; Bledsoe, Amber; Vijaykumar, Sathya; Anderson, Terry; Zawalski, Ivy; Zimmerman, Joshua

2016-06-15

The financial health care crisis has provided the platform to drive operational improvements at US health care facilities. This has led to adoption of lean operation principles by many health care organizations as a means of eliminating waste and improving operational efficiencies and overall value to patients. We believe that standardized implementation of national practice guidelines can provide the framework to help to reduce financial waste. We analyzed our institutional preoperative electrocardiogram (ECG) ordering practices for patients undergoing elective surgery at our institution from February-March, 2012 to identify utilization and review compliance with American Heart Association guidelines. We then implemented an ECG ordering algorithm based on these guidelines and studied changes in ordering patterns, associated cost savings and hospital billing for the same period in 2013. From February-March 2012, 677 noncardiac surgical procedures were performed at our institution, and 312 (46.1%) had a preoperative ECG. After implementation of our evidence-based ECG ordering algorithm for the same period in 2013, 707 noncardiac surgical cases were performed, and 120 (16.9%) had a preoperative ECG. Preoperative ECG utilization dropped 63% with an annual institutional cost savings of $72,906 and $291,618 in total annual health care savings. Based on our data, US-wide implementation of our evidence-based ECG ordering algorithm could save the US health care system >$1,868,800,000 per year. Here, we demonstrate that standardized application of a national practice guideline can be used to eliminate nearly $2 billion per year in waste from the US health care system. Copyright © 2016 Elsevier Inc. All rights reserved.

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain

PubMed Central

2014-01-01

Background Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. Methods We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Results Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Conclusions Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process. PMID:24428945

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain.

PubMed

Rutten, Geert M; Harting, Janneke; Bartholomew, Leona K; Braspenning, Jozé C; van Dolder, Rob; Heijmans, Marcel Fgj; Hendriks, Erik Jm; Kremers, Stef Pj; van Peppen, Roland Ps; Rutten, Steven Tj; Schlief, Angelique; de Vries, Nanne K; Oostendorp, Rob Ab

2014-01-15

Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.

[Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study].

PubMed

Gutiérrez-Alba, Gaudencio; González-Block, Miguel Ángel; Reyes-Morales, Hortensia

2015-01-01

To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.

Prophylaxis against Deep Venous Thrombosis in Patients Hospitalized in Surgical Wards in One of the Hospitals in Iran: Based on the American College of Chest Physician's Protocol.

PubMed

Shohani, Masoumeh; Mansouri, Akram; Norozi, Siros; Parizad, Naser; Azami, Milad

2018-01-01

There is not enough studies to determine the frequency of using the prophylaxis against deep venous thrombosis (DVT) based on the American College of Chest Physician's (ACCP) guidelines in Iran. Thus, providing such statistics is essential to improve thromboprophylaxis in hospital. The present study aimed to determine the frequency of using the prophylaxis against DVT based on ACCP guidelines in patients hospitalized in surgical wards in one of teaching hospital in Ilam, Iran. In a cross-sectional, the samples were selected among medical records of patients who were hospitalized and underwent surgery in surgical wards of the hospital from April 2012 to September 2013. Type of prophylaxis was determined based on ACCP guidelines. After reviewing inclusion and exclusion criteria, patients' data were extracted from medical records based on required variables. In reviewing 169 qualified samples, 46.2% (78 patients) were women. Of these, 132 patients were at risk of DVT and needed prophylaxis, only 39 patients (29.5%) received prophylaxis. Thromboprophylaxis based on ACCP guidelines had been fully implemented only in 30 cases (22.7%) of patients with the risk of DVT.. The highest thromboprophylaxis was in the intensive care unit (46.6%) and neurosurgery (37.5%), and the least rate was in urology (0%). As the results of this study, there are differences between clinical practice and the ACCP guidelines recommendation in prophylaxis against DVT. Thromboprophylaxis has not been implemented based on ACCP guidelines in more than 75% of patients with the risk of DVT. Thus, new strategies are needed to implement thromboprophylaxis against DVT in Iranian hospitals.

Compliance with guidelines in patients with ST-segment elevation myocardial infarction after implementation of specific guidelines for emergency care: results of RESCA+31 registry.

PubMed

Sandouk, Abbas; Ducassé, Jean-Louis; Grolleau, Sabrina; Azéma, Olivier; Elbaz, Meyer; Farah, Bruno; Tidjane, Amir; Kelly-Irving, Michelle; Charpentier, Sandrine

2012-05-01

Guidelines emphasize the implementation of local networks with prehospital emergency medical systems to improve the management of patients with ST-segment elevation myocardial infarction (STEMI); they also define the choice of reperfusion strategies and adjunctive treatments. To assess the compliance of STEMI emergency care with current French guidelines in a large area of France and to identify predictors of compliance with guidelines. The RESCA+31 registry was a 2-year, multicentre, prospective, multidisciplinary study, including 512 consecutive patients with STEMI evolving within 12 hours managed by emergency physicians in the prehospital system or emergency department. Data were recorded during the emergency phase and after admission to cardiology. First medical contact (FMC) was prehospital emergency care for 80% of patients; 97% received reperfusion treatment and 98% were admitted to a cardiology intensive care unit (CICU) with a catheterization laboratory. The mortality rate was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for adjunctive treatments and in 23% for both. The only factor independently associated with guideline compliance was FMC by prehospital emergency system. In 52% of cases, emergency physicians underestimated the delay between FMC and admission to a CICU. Despite the implementation of a network, compliance with guidelines for reperfusion strategies and adjunctive treatments was insufficient in our area. However, very few patients did not receive reperfusion therapy and the mortality rate was low. Efforts should be made to improve the estimation of delay before primary percutaneous coronary intervention. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Guidelines for Implementing State Skill Standards Certificate Program in Construction.

ERIC Educational Resources Information Center

Wisconsin State Dept. of Workforce Development, Madison.

This packet contains guidelines, a student competency checklist, and student evaluation sheet for use in a Wisconsin school-to-work state skill standards certificate program in construction. The guidelines provide a planning resource for implementing the program, which was created in partnership with unions, employers, the state Department of…

Association for Counselor Education and Supervision Guidelines for Research Mentorship: Development and Implementation

ERIC Educational Resources Information Center

Borders, L. DiAnne; Wester, Kelly L.; Granello, Darcy Haag; Chang, Catherine Y.; Hays, Danica G.; Pepperell, Jennifer; Spurgeon, Shawn L.

2012-01-01

The authors describe guidelines endorsed by the Association for Counselor Education and Supervision for research mentorship, including characteristics of mentors and mentees. Suggestions for implementing the guidelines at the individual, program, institution, and professional levels are focused on enhancing mentoring relationships as well as…

40 CFR 256.01 - Purpose and scope of the guidelines.

Code of Federal Regulations, 2010 CFR

2010-07-01

... WASTES GUIDELINES FOR DEVELOPMENT AND IMPLEMENTATION OF STATE SOLID WASTE MANAGEMENT PLANS Purpose... guidelines is to assist in the development and implementation of State solid waste management plans, in accordance with section 4002(b) of the Solid Waste Disposal Act, as amended by the Resource Conservation and...

Implementation of treatment guidelines to support judicious use of antibiotic therapy.

PubMed

Deuster, S; Roten, I; Muehlebach, S

2010-02-01

Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice. A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained. The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P < 0.001). The follow-up analysis showed a decrease in guideline adherence to 39% in patients with UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0.05). Antibiotic treatment guidelines for the infections most commonly occurring in hospitalized patients resulted in a significant increase in appropriate antibiotic use. The program was successful in changing prescription practice and achieved a sustained optimization of HAP therapy. Implementing, teaching and monitoring treatment guidelines can have a major impact on patient care.

Assessment of Critical Care Provider's Application of Preventive Measures for Ventilator-Associated Pneumonia in Intensive Care Units.

PubMed

Bagheri-Nesami, Masoumeh; Amiri-Abchuyeh, Maryam; Gholipour-Baradari, Afshin; Yazdani-Cherati, Jamshid; Nikkhah, Attieh

2015-08-01

The implementation of guidelines for the prevention of Ventilator-associated pneumonia has been shown to have a significant effect in reducing the incidence of VAP. The aim of the present study was to evaluate the implementation of the preventive strategies for VAP in ICUs of university hospitals of Sari, Iran. This cross-sectional study was carried out in 600 beds/day in the ICUs of university hospitals of Sari from April to June 2012. Sampling was done by availability technique in patients receiving mechanical ventilation in the ICU. The implementation of the preventive measures was assessed by a standard checklist with previously approved validity and reliability. The percentage of implementing each of the measures was as follows: sterile suction, 88.44%; semi-recumbent position, 76.8%; oral hygiene, 58.45%; using heat and moisture exchanges (HMEs), 58%; controlling cuff pressure, 46.8%; hand hygiene, 32.8%; using anti-coagulants, 26.8% and physiotherapy, 25.5%. Closed suction system, continuous drainage of subglottic secretions and kinetic beds were not used at all. The overall mean percentage of implementing preventive measures was low and required designing integrated guidelines by considering the conditions of the ICUs in each country, as well as educating and encouraging the staffs to use the recommended guidelines.

Implementation of national body contouring surgery guidelines following massive weight loss: A national cross-sectional survey of commissioning in England.

PubMed

Dunne, Jonathan A; Wormald, Justin C R; Ghedia, Reshma; Soldin, Mark

2017-01-01

National guidelines for commissioning of body contouring surgery (BCS) following massive weight loss (MWL) in England were published in 2014. Nearly three-quarters of patients who have MWL seek BCS; however, access is known to vary according to the region. The aim of national guidelines was to standardise access. The purpose of this study was to determine implementation of the national guidelines by clinical commissioning groups (CCGs) in England. A cross-sectional, web-based survey was sent to all CCG chairs in England. Of 211 potential respondents, 108 completed the survey or provided funding guidelines (response rate = 52%). Eight CCGs (7%) had implemented the guidelines. A total of 69 CCGs were aware of the new guidelines (64%), and 66 CCGs stated that they fund BCS after MWL (61%). A total of 81 CCGs (75%) identified local funding guidelines, while 15 CCGs (14%) cited individual funding requests (IFRs) as the means of accessing funding. To improve patient access to BCS; 58 of 65 respondents (89%) stated cost-effectiveness, whereas 56 of 75 respondents (75%) thought patient-reported outcome measures were key. Qualitative data to improve access included an integrated pathway from bariatric surgery to BCS, an improved evidence base and greater CCG finances. One CCG stated that it cannot afford to fund cosmetic procedures. The purpose of national guidelines was to simplify the pathway to BCS after MWL and create fair distribution of funds across the country to needy patients; however, their uptake has been poor. Access to funding for BCS across England varies according to the location. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Implementation of national guidelines for the prevention and treatment of overweight and obesity in children and adolescents: a phenomenographic analysis of public health nurses' perceptions.

PubMed

Nordstrand, Aina; Fridlund, Bengt; Sollesnes, Ragnhild

2016-01-01

To explore and describe how public health nurses (PHNs) perceive the implementation of national guidelines for the prevention and treatment of overweight and obesity among children and adolescents in well-baby clinics and school health services. An explorative descriptive design was carried out through individual interviews with 18 PHNs and analysed according to the phenomenographic tradition. Four implementation strategies were described and assigned a metaphor: the structured PHN, pragmatic PHN, critical PHN, and the resigned PHN. Competence, patient receptiveness, internal consensus, interdisciplinary collaboration, resources, and organizational embedding were the determinants identified that most frequently affect implementation, and these determinants were distributed at different levels of the organization. The extent of facilitation seemed to determine which implementation strategy would be used. How PHNs implemented the guidelines for overweight and obesity were affected by determinants at different organizational levels. Contextual facilitation of implementation seemed better in larger organizations, but factors such as leadership, drive, and experience compensated in smaller municipalities. The implementation of guidelines was hindered when the barriers exceeded the benefits.

Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development

PubMed Central

2012-01-01

Clinical practice guidelines are one of the foundations of efforts to improve health care. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearing houses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this third paper we discuss the issues of: reviewing, reporting, and publishing guidelines; updating guidelines; and the two emerging issues of enhancing guideline implementability and how guideline developers should approach dealing with the issue of patients who will be the subject of guidelines having co-morbid conditions. PMID:22762242

Implementing Recommendations From Web Accessibility Guidelines: A Comparative Study of Nondisabled Users and Users With Visual Impairments.

PubMed

Schmutz, Sven; Sonderegger, Andreas; Sauer, Juergen

2017-09-01

The present study examined whether implementing recommendations of Web accessibility guidelines would have different effects on nondisabled users than on users with visual impairments. The predominant approach for making Web sites accessible for users with disabilities is to apply accessibility guidelines. However, it has been hardly examined whether this approach has side effects for nondisabled users. A comparison of the effects on both user groups would contribute to a better understanding of possible advantages and drawbacks of applying accessibility guidelines. Participants from two matched samples, comprising 55 participants with visual impairments and 55 without impairments, took part in a synchronous remote testing of a Web site. Each participant was randomly assigned to one of three Web sites, which differed in the level of accessibility (very low, low, and high) according to recommendations of the well-established Web Content Accessibility Guidelines 2.0 (WCAG 2.0). Performance (i.e., task completion rate and task completion time) and a range of subjective variables (i.e., perceived usability, positive affect, negative affect, perceived aesthetics, perceived workload, and user experience) were measured. Higher conformance to Web accessibility guidelines resulted in increased performance and more positive user ratings (e.g., perceived usability or aesthetics) for both user groups. There was no interaction between user group and accessibility level. Higher conformance to WCAG 2.0 may result in benefits for nondisabled users and users with visual impairments alike. Practitioners may use the present findings as a basis for deciding on whether and how to implement accessibility best.

The rural health care workforce implications of practice guideline implementation.

PubMed

Yawn, B P; Casey, M; Hebert, P

1999-03-01

Rural health care workforce forecasting has not included adjustments for predictable changes in practice patterns, such as the introduction of practice guidelines. To estimate the impact of a practice guideline for a single health condition on the needs of a rural health professional workforce. The current care of a cohort of rural Medicare recipients with diabetes mellitus was compared with the care recommended by a diabetes practice guideline. The additional tests and visits that were needed to comply with the guideline were translated into additional hours of physician services and total physician full-time equivalents. The implementation of a practice guideline for Medicare recipients with diabetes in rural Minnesota would require over 30,000 additional hours of primary care physician services and over 5,000 additional hours of eye care professionals' time per year. This additional need represents a 1.3% to 2.4% increase in the number of primary care physicians and a 1.0% to 6.6% increase in the number of eye-care clinicians in a state in which the rural medical provider to population ratios already meet some recommended workforce projections. The implementation of practice guidelines could result in an increased need for rural health care physicians or other providers. That increase, caused by guideline implementation, should be accounted for in future rural health care workforce predictions.

Improving quality of care for depression: the German Action Programme for the implementation of evidence-based guidelines.

PubMed

Härter, Martin; Bermejo, Isaac; Ollenschläger, Günter; Schneider, Frank; Gaebel, Wolfgang; Hegerl, Ulrich; Niebling, Wilhelm; Berger, Mathias

2006-04-01

Depressive disorders are of great medical and political significance. The potential inherent in achieving better guideline orientation and a better collaboration between different types of care is clear. Throughout the 1990s, educational initiatives were started for implementing guidelines. Evidence-based guidelines on depression have been formulated in many countries. This article presents an action programme for structural, educational, and research-related measures to implement evidence-based care of depressive disorders in the German health system. The starting points of the programme are the 'Guidelines Critical Appraisal Reports' of the 'Guideline Clearing House' and measures from the 'Competence Network on Depression and Suicidality' (CNDS) funded by the Federal Ministry of Education and Research. The article gives an overview of the steps achieved as recommended by the Guidelines Critical Appraisal Reports and the ongoing transfer process into the German health care system. The action programme shows that comprehensive interventions to develop and introduce evidence-based guidelines for depression can achieve benefits in the care of depression, e.g. in recognition, management, and clinical outcome. It was possible to implement the German Action Programme in selected care settings, and initial evaluation results suggest some improvements. The action programme provides preliminary work, materials, and results for developing a future 'Disease Management Programme' (DMP) for depression.

Stakeholder perspectives on implementing a universal Lynch syndrome screening program: a qualitative study of early barriers and facilitators.

PubMed

Schneider, Jennifer L; Davis, James; Kauffman, Tia L; Reiss, Jacob A; McGinley, Cheryl; Arnold, Kathleen; Zepp, Jamilyn; Gilmore, Marian; Muessig, Kristin R; Syngal, Sapna; Acheson, Louise; Wiesner, Georgia L; Peterson, Susan K; Goddard, Katrina A B

2016-02-01

Evidence-based guidelines recommend that all newly diagnosed colon cancer be screened for Lynch syndrome (LS), but best practices for implementing universal tumor screening have not been extensively studied. We interviewed a range of stakeholders in an integrated health-care system to identify initial factors that might promote or hinder the successful implementation of a universal LS screening program. We conducted interviews with health-plan leaders, managers, and staff. Interviews were audio-recorded and transcribed. Thematic analysis began with a grounded approach and was also guided by the Practical Robust Implementation and Sustainability Model (PRISM). We completed 14 interviews with leaders/managers and staff representing involved clinical and health-plan departments. Although stakeholders supported the concept of universal screening, they identified several internal (organizational) and external (environment) factors that promote or hinder implementation. Facilitating factors included perceived benefits of screening for patients and organization, collaboration between departments, and availability of organizational resources. Barriers were also identified, including: lack of awareness of guidelines, lack of guideline clarity, staffing and program "ownership" concerns, and cost uncertainties. Analysis also revealed nine important infrastructure-type considerations for successful implementation. We found that clinical, laboratory, and administrative departments supported universal tumor screening for LS. Requirements for successful implementation may include interdepartmental collaboration and communication, patient and provider/staff education, and significant infrastructure and resource support related to laboratory processing and systems for electronic ordering and tracking.

[An evaluation of the implementation of the 'Guidelines for oral care for patients dependent on care'].

PubMed

Hoeksema, A R; Meijer, H J A; Vissink, A; Raghoebar, G M; Visser, A

2016-05-01

75% of older people being admitted to a nursing home are found to have oral care problems that have not been treated. Moreover, the Healthcare Inspectorate [in the Netherlands] reports that oral care for patients who depend on care in nursing homes is inadequate. The 'Guidelines for oral care for patients dependent on care in nursing homes', developed in 2007, appears to have been inadequately implemented. The goal of this research was to gain insight into the implementation of these guidelines in healthcare organisations. To that end, a questionnaire was distributed among the staff of 74 nursing homes. An analysis of the data revealed that people are -familiar with the guidelines and that oral care providers are often available. Oral care providers, however, often do not have access to reasonable dental care facilities. Patients are, moreover, generally not screened and/or monitored in accordance with the guidelines. Finally, it seems that the instruction of nurses and care-providers is insufficient. Research supports the conclusion that the nursing home staff is well-acquainted with the 'Guidelines for oral care for patients dependent on care' but that implementation of the guidelines in daily practice leaves much to be desired.

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

PubMed

Brennan, Penny L; Del Re, Aaron C; Henderson, Patricia T; Trafton, Jodie A

2016-12-01

This study provides an example of how healthcare system-wide progress in implementation of opioid-therapy guideline recommendations can be longitudinally assessed and then related to subsequent opioid-prescribed patient health and safety outcomes. Using longitudinal linear mixed effects analyses, we determined that in the Department of Veterans Affairs (VA) healthcare system (n = 141 facilities), over the 4-year interval from 2010 to 2013, a key opioid therapy guideline recommendation, urine drug screening (UDS), increased from 29 to 42 %, with an average within-facility increase rate of 4.5 % per year. Higher levels of UDS implementation from 2010 to 2013 were associated with lower risk of suicide and drug overdose events among VA opioid-prescribed patients in 2013, even after adjusting for patients' 2012 demographic characteristics and medical and mental health comorbidities. Findings suggest that VA clinicians and healthcare policymakers have been responsive to the 2010 VA/Department of Defense (DOD) UDS treatment guideline recommendation, resulting in improved patient safety for VA opioid-prescribed patients.

Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study.

PubMed

Boadu, Nana Yaa; Amuasi, John; Ansong, Daniel; Einsiedel, Edna; Menon, Devidas; Yanow, Stephanie K

2016-02-27

Rapid diagnostic Tests (RDTs) for malaria enable diagnostic testing at primary care facilities in resource-limited settings, where weak infrastructure limits the use of microscopy. In 2010, Ghana adopted a test-before-treat guideline for malaria, with RDT use promoted to facilitate diagnosis. Yet healthcare practitioners still treat febrile patients without testing, or despite negative malaria test results. Few studies have explored RDT implementation beyond the notions of provider or patient acceptability. The aim of this study was to identify the factors directly influencing malaria RDT implementation at primary care facilities in a Ghanaian district. Qualitative interviews, focus groups and direct observations were conducted with 50 providers at six purposively selected primary care facilities in the Atwima-Nwabiagya district. Data were analysed thematically. RDT implementation was hampered by: (1) healthcare delivery constraints (weak supply chain, limited quality assurance and control, inadequate guideline emphasis, staffing limitations); (2) provider perceptions (entrenched case-management paradigms, limited preparedness for change); (3) social dynamics of care delivery (expected norms of provider-patient interaction, test affordability); and (4) limited provider engagement in policy processes leading to fragmented implementation of health sector reform. Limited health system capacity, socio-economic, political, and historical factors hampered malaria RDT implementation at primary care facilities in the study district. For effective RDT implementation providers must be: (1) adequately enabled through efficient allocation and management of essential healthcare commodities; (2) appropriately empowered with the requisite knowledge and skill through ongoing, effective professional development; and (3) actively engaged in policy dialogue to demystify socio-political misconceptions that hinder health sector reform policies from improving care delivery. Clear, consistent guideline emphasis, with complementary action to address deep-rooted provider concerns will build their confidence in, and promote uptake of recommended policies, practices, and technology for diagnosing malaria.

Adherence To Diabetes Mellitus Treatment Guidelines From Theory To Practice: The Missing Link.

PubMed

Hashmi, Noreen Rahat; Khan, Shahzad Ali

2016-01-01

Diabetes mellitus is a complex multisystem disease that requires high quality care. Clinical practice guidelines help physicians and patients make the best possible health care decisions and improve health care management of diabetic patients. These guidelines provide the norms for clinical management as well as monitoring of diabetes care. They are not simple algorithms but are based on structured evidence based diabetic management protocols developed from randomized controlled trials. Despite the widespread availability of this diabetic guideline, their use is suboptimal at best. There are several factors blamed for contributing to this missing link from available theoretical guideline recommendations to practical applications of these guidelines. We present a brief review based on available literature review for an ongoing interventional study being done by authors in two tertiary care hospital in Lahore Pakistan for improving adherence to diabetes guidelines. We will discuss guideline implementation cycle and also present a framework encompassing various factors involved in adherence to guidelines. Until recently the emphasis to improve the guideline adherence targeted the factors relating to individual health care professionals in reference to their knowledge, attitude practice of the guidelines. However, we will discuss that broader range of health care systems, organizational factors, and factors relating to patients which may also significantly impact the adherence to the guidelines. The framework emphasises that it is important to understand the factors that act as barriers and contribute to the missing link between theory and practice of diabetic guidelines. This will help plan appropriate strategies in the pre-implementation stage for effective and improved diabetes guidelines adherence and management.

The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature.

PubMed

Koornneef, Erik; Robben, Paul; Hajat, Cother; Ali, Azhar

2015-12-01

Our aim was to examine and describe the current situation in Gulf Cooperation Council (GCC) member countries regarding the development, implementation and evaluation of clinical practice guidelines (CPG). The objectives were to describe from where the studies originated, what the clinical focus was of each study and examine the methodology and the status of each study (i.e. development, dissemination, implementation and evaluation). Review of literature - two stages: stage 1: screening through an abstract review, followed by independent adjudicator; stage 2: detailed assessment and classification. Considering the widespread acceptance that CPG's are useful and effective tools for quality improvement in health care, it is worth noting that relatively few studies have been conducted in the GCC region that examine CPG. Furthermore, the reviewers found that the quality of the research methods used could be improved. The majority of the studies that were conducted evaluated the effects of guidelines and focused on the 'lifestyle diseases', in particular diabetes and cardiovascular diseases. It is also worth noting that there has been a steady increase in the number of publications over the 10 years period. More attention needs to be given to developing, disseminating, implementing and evaluating CPG's in the GCC region in order to improve the quality and safety of health care. © 2015 John Wiley & Sons, Ltd.

Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines.

PubMed

Pitetti, Raymond; Davis, Peter J; Redlinger, Robert; White, Jean; Wiener, Eugene; Calhoun, Karen H

2006-02-01

To describe the effect of implementing the Joint Commission on Accreditation of Healthcare Organization's guidelines for procedural sedation and analgesia (PSA) on the frequency of adverse events occurring during sedation. Prospective, descriptive study. Urban, tertiary care children's hospital. Patients requiring PSA. A PSA committee and a standardized protocol for PSA were developed during a 6-month period. Institutional oversight was initiated to monitor practitioner compliance with the program. Data were abstracted from the sedation record. The change in incidence of adverse events during PSA during the study. The strength of the association was determined by computing the Pearson product moment correlation. A total of 14 386 patients received PSA between July 1, 2001, and June 30, 2004. During the study, 7.6% of patients had an adverse event, with the most common being hypoxemia (39.7% of all adverse events). A trend toward a decrease in the incidence of adverse events was found during the study (Pearson product moment correlation, -0.68; P<.001). Implementation of the 2001 Joint Commission on Accreditation of Healthcare Organizations guidelines for the provision of PSA appeared to lead to a decrease in the incidence of adverse events during the study. Implementation of uniform standards of monitoring and care for the provision of PSA may lead to safer conditions for pediatric patients undergoing PSA.

Impact of revisions to the F-Tag 309 surveyors' interpretive guidelines on pain management among nursing home residents.

PubMed

Lapane, Kate L; Quilliam, Brian J; Chow, Wing; Kim, Myoung S

2012-05-01

On 31 March 2009, the US Centers for Medicare & Medicaid Services (CMS) provided revised guidance for meeting compliance in the evaluation and management of pain in nursing home residents, known as F-Tag 309. The aim of the study was to estimate the extent to which implementation of revisions to the surveyors' interpretive guidelines for F-Tag 309 improved recognition and management of pain among nursing home residents. The impact of the revisions to guidance on F-Tag 309 on pain in nursing home residents was investigated. The study was quasi-experimental in design and included 174 for-profit nursing homes in 19 US states. Nursing home residents with ≥2 Minimum Data Set (MDS) assessments between 1 January 2007 and 30 March 2009 (before the revisions to the guidelines; n = 8449) and between 31 March 2009 and 31 December 2009 (after the revisions; n = 1400) were included. The MDS assessments provided information on pain, analgesic use and cognitive, functional and emotional status. Separate logistic regression models that adjusted for clustering effects of residents residing in nursing homes provided estimates of the relationship between the implementation of the revisions to F-Tag 309 and the prevalence of pain and its management. Pain was more likely to be documented in the period after the revisions were implemented. The odds of pain being documented on at least one of two consecutive MDS assessments increased after the revisions to the guidelines were implemented (adjusted odds ratio [OR] 1.15; 95% confidence interval [CI] 1.01, 1.31). Increases in scheduled analgesic prescription were observed in the post-revision era (adjusted OR 1.38; 95% CI 1.21,1.57). The implementation of revisions to the surveyors' interpretive guidelines for F-Tag 309 improved recognition and management of pain as well as analgesic use in nursing home residents with documented non-cancer pain. Use of directed language as part of the surveyors' interpretive guidelines may be a viable approach to stimulating improvements in pain documentation and management.

28 CFR 63.8 - Implementation.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Implementation. 63.8 Section 63.8... PROCEDURES § 63.8 Implementation. Agencies and divisions within the Department of Justice shall amend... these guidelines. Such amendments will be made within 6 months of final publication of these guidelines. ...

28 CFR 63.8 - Implementation.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Implementation. 63.8 Section 63.8... PROCEDURES § 63.8 Implementation. Agencies and divisions within the Department of Justice shall amend... these guidelines. Such amendments will be made within 6 months of final publication of these guidelines. ...

28 CFR 63.8 - Implementation.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Implementation. 63.8 Section 63.8... PROCEDURES § 63.8 Implementation. Agencies and divisions within the Department of Justice shall amend... these guidelines. Such amendments will be made within 6 months of final publication of these guidelines. ...

28 CFR 63.8 - Implementation.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Implementation. 63.8 Section 63.8... PROCEDURES § 63.8 Implementation. Agencies and divisions within the Department of Justice shall amend... these guidelines. Such amendments will be made within 6 months of final publication of these guidelines. ...

28 CFR 63.8 - Implementation.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Implementation. 63.8 Section 63.8... PROCEDURES § 63.8 Implementation. Agencies and divisions within the Department of Justice shall amend... these guidelines. Such amendments will be made within 6 months of final publication of these guidelines. ...

Guidelines for Technology Infrastructure in Connecticut Schools: An Implementation Guide for the Connecticut Statewide Educational Technology Plan.

ERIC Educational Resources Information Center

Center for Educational Leadership and Technology, Inc., Marlborough, MA.

This document presents guidelines and recommendations for development of a technology infrastructure in Connecticut public schools that conforms to national industry standards for voice, video, and data communications. The guidelines present information on the state statutes regarding facilities implementation and describe industry standards.…

49 CFR Appendix C to Part 224 - Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 4 2011-10-01 2011-10-01 false Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports C Appendix C to Part 224 Transportation Other Regulations... REFLECTORIZATION OF RAIL FREIGHT ROLLING STOCK Pt. 224, App. C Appendix C to Part 224—Guidelines for Electronic...

2 CFR 180.20 - What must a Federal agency do to implement these guidelines?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 2 Grants and Agreements 1 2010-01-01 2010-01-01 false What must a Federal agency do to implement these guidelines? 180.20 Section 180.20 Grants and Agreements OFFICE OF MANAGEMENT AND BUDGET GOVERNMENTWIDE GUIDANCE FOR GRANTS AND AGREEMENTS Reserved OMB GUIDELINES TO AGENCIES ON GOVERNMENTWIDE DEBARMENT...

2 CFR 180.30 - Where does a Federal agency implement these guidelines?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 2 Grants and Agreements 1 2010-01-01 2010-01-01 false Where does a Federal agency implement these guidelines? 180.30 Section 180.30 Grants and Agreements OFFICE OF MANAGEMENT AND BUDGET GOVERNMENTWIDE GUIDANCE FOR GRANTS AND AGREEMENTS Reserved OMB GUIDELINES TO AGENCIES ON GOVERNMENTWIDE DEBARMENT AND...

2 CFR 180.35 - By when must a Federal agency implement these guidelines?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 2 Grants and Agreements 1 2010-01-01 2010-01-01 false By when must a Federal agency implement these guidelines? 180.35 Section 180.35 Grants and Agreements OFFICE OF MANAGEMENT AND BUDGET GOVERNMENTWIDE GUIDANCE FOR GRANTS AND AGREEMENTS Reserved OMB GUIDELINES TO AGENCIES ON GOVERNMENTWIDE DEBARMENT...

49 CFR Appendix C to Part 224 - Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 4 2014-10-01 2014-10-01 false Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports C Appendix C to Part 224 Transportation Other Regulations... REFLECTORIZATION OF RAIL FREIGHT ROLLING STOCK Pt. 224, App. C Appendix C to Part 224—Guidelines for Electronic...

49 CFR Appendix C to Part 224 - Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 4 2013-10-01 2013-10-01 false Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports C Appendix C to Part 224 Transportation Other Regulations... REFLECTORIZATION OF RAIL FREIGHT ROLLING STOCK Pt. 224, App. C Appendix C to Part 224—Guidelines for Electronic...

49 CFR Appendix C to Part 224 - Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Guidelines for Electronic Submission of Reflectorization Implementation Compliance Reports C Appendix C to Part 224 Transportation Other Regulations... REFLECTORIZATION OF RAIL FREIGHT ROLLING STOCK Pt. 224, App. C Appendix C to Part 224—Guidelines for Electronic...

'How to know what you need to do': a cross-country comparison of maternal health guidelines in Burkina Faso, Ghana and Tanzania.

PubMed

Baker, Ulrika; Tomson, Göran; Somé, Mathias; Kouyaté, Bocar; Williams, John; Mpembeni, Rose; Massawe, Siriel; Blank, Antje; Gustafsson, Lars L; Eriksen, Jaran

2012-04-13

Initiatives to raise the quality of care provided to mothers need to be given priority in Sub Saharan Africa (SSA). The promotion of clinical practice guidelines (CPGs) is a common strategy, but their implementation is often challenging, limiting their potential impact. Through a cross-country perspective, this study explored CPGs for maternal health in Burkina Faso, Ghana, and Tanzania. The objectives were to compare factors related to CPG use including their content compared with World Health Organization (WHO) guidelines, their format, and their development processes. Perceptions of their availability and use in practice were also explored. The overall purpose was to further the understanding of how to increase CPGs' potential to improve quality of care for mothers in SSA. The study was a multiple case study design consisting of cross-country comparisons using document review and key informant interviews. A conceptual framework to aid analysis and discussion of results was developed, including selected domains related to guidelines' implementability and use by health workers in practice in terms of usability, applicability, and adaptability. The study revealed few significant differences in content between the national guidelines for maternal health and WHO recommendations. There were, however, marked variations in the format of CPGs between the three countries. Apart from the Ghanaian and one of the Tanzanian CPGs, the levels of both usability and applicability were assessed as low or medium. In all three countries, the use of CPGs by health workers in practice was perceived to be limited. Our cross-country study suggests that it is not poor quality of content or lack of evidence base that constitute the major barrier for CPGs to positively impact on quality improvement in maternal care in SSA. It rather emphasises the need to prioritise the format of guidelines to increase their usability and applicability and to consider these attributes together with implementation strategies as integral to their development processes.

Drug Administration via Enteral Feeding Tube in Residential Care Facilities for Individuals with Intellectual Disability: A Focus Group Study on Guideline Implementation

ERIC Educational Resources Information Center

Joos, Elke; Van Tongelen, Inge; Wijnants, Karen; Mehuys, Els; Van Bocxlaer, Jan; Remon, Jean Paul; Grypdonck, Maria; Van Winckel, Myriam; Boussery, Koen

2016-01-01

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present…

A look at statin cost-effectiveness in view of the 2013 ACC/AHA cholesterol management guidelines.

PubMed

Deaño, Roderick C; Pandya, Ankur; Jones, Erica C; Borden, William B

2014-09-01

The 2013 cholesterol management guidelines presented a major shift in recommendations on which patients at risk of cardiovascular disease should be treated and how to treat them. Implementation of the guidelines is estimated to increase substantially the number of people who would be eligible for statin therapy. As the medical community considers the broad population impact of the new cholesterol guidelines, the issue of cost-effectiveness plays a role. This review covers the basic fundamentals of cost-effectiveness analysis and summarizes the key cost-effectiveness studies that relate to the new cholesterol guidelines.

75 FR 9878 - Draft Principles and Standards Sections of the “Economic and Environmental Principles and...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-04

... COUNCIL ON ENVIRONMENTAL QUALITY Draft Principles and Standards Sections of the ``Economic and Environmental Principles and Guidelines for Water and Related Land Resources Implementation Studies... the ``Economic and Environmental Principles and Guidelines for Water and Related Land Resources...

Implementation of a clinical practice guideline for antenatal magnesium sulphate for neuroprotection in Australia and New Zealand.

PubMed

Bain, Emily; Bubner, Tanya; Ashwood, Pat; Crowther, Caroline A; Middleton, Philippa

2013-02-01

Health professionals at 25 Australian and New Zealand tertiary maternity hospitals were surveyed about local implementation of a clinical practice guideline for antenatal magnesium sulphate for fetal neuroprotection. Seventy-six percent of respondents reported that their hospital is currently following a guideline; 36% confirmed that their hospital is auditing uptake. Estimates of uptake ranged from 53 to 90%. Ongoing education and support are needed to ensure that the guidelines are optimally implemented, and uptake and important health outcomes are monitored. © 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

[The German program for disease management guidelines--implementation with pathways and quality management].

PubMed

Ollenschläger, Günter; Lelgemann, Monika; Kopp, Ina

2007-07-15

In Germany, physicians enrolled in disease management programs are legally obliged to follow evidence-based clinical practice guidelines. That is why a Program for National Disease Management Guidelines (German DM-CPG Program) was established in 2002 aiming at implementation of best-practice evidence-based recommendations for nationwide as well as regional disease management programs. Against this background the article reviews programs, methods and tools for implementing DM-CPGs via clinical pathways as well as regional guidelines for outpatient care. Special reference is given to the institutionalized program of adapting DM-CPGs for regional use by primary-care physicians in the State of Hesse.

SPAN security policies and guidelines

NASA Technical Reports Server (NTRS)

Sisson, Patricia L.; Green, James L.

1989-01-01

A guide is provided to system security with emphasis on requirements and guidelines that are necessary to maintain an acceptable level of security on the network. To have security for the network, each node on the network must be secure. Therefore, each system manager, must strictly adhere to the requirements and must consider implementing the guidelines discussed. There are areas of vulnerability within the operating system that may not be addressed. However, when a requirement or guideline is discussed, implementation techniques are included. Information related to computer and data security is discussed to provide information on implementation options. The information is presented as it relates to a VAX computer environment.

A scalable architecture for incremental specification and maintenance of procedural and declarative clinical decision-support knowledge.

PubMed

Hatsek, Avner; Shahar, Yuval; Taieb-Maimon, Meirav; Shalom, Erez; Klimov, Denis; Lunenfeld, Eitan

2010-01-01

Clinical guidelines have been shown to improve the quality of medical care and to reduce its costs. However, most guidelines exist in a free-text representation and, without automation, are not sufficiently accessible to clinicians at the point of care. A prerequisite for automated guideline application is a machine-comprehensible representation of the guidelines. In this study, we designed and implemented a scalable architecture to support medical experts and knowledge engineers in specifying and maintaining the procedural and declarative aspects of clinical guideline knowledge, resulting in a machine comprehensible representation. The new framework significantly extends our previous work on the Digital electronic Guidelines Library (DeGeL) The current study designed and implemented a graphical framework for specification of declarative and procedural clinical knowledge, Gesher. We performed three different experiments to evaluate the functionality and usability of the major aspects of the new framework: Specification of procedural clinical knowledge, specification of declarative clinical knowledge, and exploration of a given clinical guideline. The subjects included clinicians and knowledge engineers (overall, 27 participants). The evaluations indicated high levels of completeness and correctness of the guideline specification process by both the clinicians and the knowledge engineers, although the best results, in the case of declarative-knowledge specification, were achieved by teams including a clinician and a knowledge engineer. The usability scores were high as well, although the clinicians' assessment was significantly lower than the assessment of the knowledge engineers.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.

PubMed

Ostroff, Jamie S; Li, Yuelin; Shelley, Donna R

2014-02-21

Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence. Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence. We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices. NCT01615237.

Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature.

PubMed

Brooks, Steven C; Morrison, Laurie J

2008-06-01

The 2005 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations document represents the most extensive and rigorous systematic review of the resuscitation literature to date and included evidence-based recommendations for post-resuscitation care. A new recommendation for the induction of mild therapeutic hypothermia for comatose cardiac arrest survivors was included in this document. Accordingly, constituent national member associations of ILCOR, including the American Heart Association, incorporated the recommendation for therapeutic hypothermia into their respective guidelines. Despite these endorsements there is a concern that therapeutic hypothermia is not being used in practice. Data from a number of surveys in Europe and the United States suggest that rates of use among physicians may be as low as 30-40%. Despite the cost and effort associated with the production of these guidelines and the potential impact on patient care, current efforts in implementing the guideline have not achieved widespread success. This commentary explores the issue of underutilization of the American Heart Association guidelines for therapeutic hypothermia and looks to the knowledge translation literature to inform a new approach to implementation. We will review the underlying phenomenon of research implementation into practice, specific barriers to guideline implementation and interventions that may improve therapeutic hypothermia uptake.

Implementing exertional heat illness prevention strategies in US high school football.

PubMed

Kerr, Zachary Y; Marshall, Stephen W; Comstock, R Dawn; Casa, Douglas J

2014-01-01

Approximately 6500 high school football athletes are treated annually for exertional heat illness (EHI). In 2009, the National Athletic Trainers Association (NATA)-led Inter-Association Task Force (NATA-IATF) released preseason heat acclimatization guidelines to help athletes become accustomed to environmental factors contributing to EHI. This study examines compliance with NATA-IATF guidelines and related EHI prevention strategies. The study used a cross-sectional survey completed by 1142 certified athletic trainers (AT), which captured compliance with 17 NATA-IATF guidelines and EHI prevention strategies in high school football during the 2011 preseason. On average, AT reported football programs complying with 10.4 NATA-IATF guidelines (SD = 3.2); 29 AT (2.5%) reported compliance with all 17. Guidelines with the lowest compliance were as follows: "Single-practice days consisted of practice no more than three hours in length" (39.7%); and "During days 3-5 of acclimatization, only helmets and shoulder pads should be worn" (39.0%). An average of 7.6 EHI prevention strategies (SD = 2.5) were used. Common EHI prevention strategies were as follows: having ice bags/cooler available (98.5%) and having a policy with written instructions for initiating emergency medical service response (87.8%). Programs in states with mandated guidelines had higher levels of compliance with guidelines and greater prevalence of EHI prevention strategies. A low proportion of surveyed high school football programs fully complied with all 17 NATA-IATF guidelines. However, many EHI prevention strategies were voluntarily implemented. State-level mandated EHI prevention guidelines may increase compliance with recognized best practices recommendations. Ongoing longitudinal monitoring of compliance is also recommended.

Optimal Pain Assessment in Pediatric Rehabilitation: Implementation of a Nursing Guideline.

PubMed

Kingsnorth, Shauna; Joachimides, Nick; Krog, Kim; Davies, Barbara; Higuchi, Kathryn Smith

2015-12-01

In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Texas Medication Algorithm Project: development and feasibility testing of a treatment algorithm for patients with bipolar disorder.

PubMed

Suppes, T; Swann, A C; Dennehy, E B; Habermacher, E D; Mason, M; Crismon, M L; Toprac, M G; Rush, A J; Shon, S P; Altshuler, K Z

2001-06-01

Use of treatment guidelines for treatment of major psychiatric illnesses has increased in recent years. The Texas Medication Algorithm Project (TMAP) was developed to study the feasibility and process of developing and implementing guidelines for bipolar disorder, major depressive disorder, and schizophrenia in the public mental health system of Texas. This article describes the consensus process used to develop the first set of TMAP algorithms for the Bipolar Disorder Module (Phase 1) and the trial testing the feasibility of their implementation in inpatient and outpatient psychiatric settings across Texas (Phase 2). The feasibility trial answered core questions regarding implementation of treatment guidelines for bipolar disorder. A total of 69 patients were treated with the original algorithms for bipolar disorder developed in Phase 1 of TMAP. Results support that physicians accepted the guidelines, followed recommendations to see patients at certain intervals, and utilized sequenced treatment steps differentially over the course of treatment. While improvements in clinical symptoms (24-item Brief Psychiatric Rating Scale) were observed over the course of enrollment in the trial, these conclusions are limited by the fact that physician volunteers were utilized for both treatment and ratings. and there was no control group. Results from Phases 1 and 2 indicate that it is possible to develop and implement a treatment guideline for patients with a history of mania in public mental health clinics in Texas. TMAP Phase 3, a recently completed larger and controlled trial assessing the clinical and economic impact of treatment guidelines and patient and family education in the public mental health system of Texas, improves upon this methodology.

Intention of physicians to implement guidelines for screening and treatment of latent tuberculosis infection in HIV-infected patients in The Netherlands: a mixed-method design.

PubMed

Evenblij, Kirsten; Verbon, Annelies; van Leth, Frank

2016-09-01

All newly diagnosed HIV-infected patients in the Netherlands should be screened for latent tuberculosis infection (LTBI) and offered preventive therapy if infected without evidence of active tuberculosis. This guideline, endorsed by the national professional body of HIV physicians is in line with international recommendations, and based on the increased risk of progression from LTBI to active tuberculosis in HIV-infected patients. The objective of the study is to assess the intention of HIV physicians to implement this national guideline. A mixed method design triangulating results from two surveys among all (n = 80) HIV physicians in The Netherlands and qualitative interviews among 11 Dutch HIV physicians performed in 2014. The majority of physicians used a risk-stratification approach based on individual a priori risk of tuberculosis to identify HIV-infected patients for LTBI screening, rather than screening all new HIV-infected patients. The intended and actual provision of preventive treatment was low, due to expressed doubts on the accuracy of diagnostic tools for LTBI. Interviewees reported that the guidelines did not match their clinical experience and lacked evidence for the recommendations. Screening for and treatment of LTBI was approached at a patient-level only. None of the interviewees referred to potential public health implications of the guidelines. Intended implementation of the national HIV-TB guidelines in the Netherlands is poor, due to a disconnect between clinical practice and evidence-based recommendations in the guideline. There is an urgent need to reconcile the views of HIV-physicians, public health experts, and guideline committee members, regarding the best strategy to address HIV-TB co-infection in the Netherlands.

[Fewer breech deliveries after implementation of a modified cephalic version protocol].

PubMed

Kuppens, Simone M I; Francois, Anne M H; Hasaart, Tom H M; van der Donk, Maria W P; Pop, Victor J M

2010-01-01

To investigate the effect of implementation of a number of process policy guidelines (protocol), on the success rate of external cephalic version (ECV) for breech presentation. Prospective study. During a 3-year period (2004-2006) a standardized protocol for an ECV consultation was developed, evaluated and adapted. After implementing this modified protocol as 'process policy guidelines', the effect on the rate of successful ECV was prospectively evaluated during the period 1 January 2007-31 July 2008. Success was defined as cephalic presentation (ultrasound) immediately after ECV. A secondary outcome measure was the elective caesarean section rate for breech presentation. The rate of successful ECV increased significantly from 47% (110/236 pregnant women) in the period January 2004-December 2006 to 61% (85/139, p = 0.006) in the period January 2007-July 2008. Patient characteristics were similar in both groups, with the exception of 2 subgroups of term of version. The increase was preferentially found in nulliparous and multiparous women with frank breech. Nulliparity, frank breech, anterior placenta and low birth weight were associated with a lower success rate of ECV. The term of pregnancy at which ECV was performed did not seem to affect the success rate. Implementing the process policy guidelines increased the number of cephalic presentations at delivery and decreased the rate of elective caesarean sections for breech presentation from 39% to 27% (p = 0.03). The number needed to treat to prevent 1 elective caesarean section by ECV according to the process policy guidelines was 8. After implementation of the process policy guidelines, the success rate of ECV increased considerably. The rate of elective caesarean section for breech presentation declined. These findings are in favour of establishing specialized ECV centres in the Netherlands.

A case of standardization? Implementing health promotion guidelines in Denmark.

PubMed

Rod, Morten Hulvej; Høybye, Mette Terp

2016-09-01

Guidelines are increasingly used in an effort to standardize and systematize health practices at the local level and to promote evidence-based practice. The implementation of guidelines frequently faces problems, however, and standardization processes may in general have other outcomes than the ones envisioned by the makers of standards. In 2012, the Danish National Health Authorities introduced a set of health promotion guidelines that were meant to guide the decision making and priority setting of Denmark's 98 local governments. The guidelines provided recommendations for health promotion policies and interventions and were structured according to risk factors such as alcohol, smoking and physical activity. This article examines the process of implementation of the new Danish health promotion guidelines. The article is based on qualitative interviews and participant observation, focusing on the professional practices of health promotion officers in four local governments as well as the field of Danish health promotion more generally. The analysis highlights practices and episodes related to the implementation of the guidelines and takes inspiration from Timmermans and Epstein's sociology of standards and standardization. It remains an open question whether or not the guidelines lead to more standardized policies and interventions, but we suggest that the guidelines promote a risk factor-oriented approach as the dominant frame for knowledge, reasoning, decision making and priority setting in health promotion. We describe this process as a case of epistemic standardization. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Educating APNs for Implementing the Guidelines for Adolescents in "Bright Futures: Guidelines of Health Supervision of Infants, Children, and Adolescents."

ERIC Educational Resources Information Center

Porter, Cornelia P.; Pender, Nola J.; Hayman, Laura L.; Armstrong, Myrna L.; Riesch, Susan K.; Lewis, Mary Ann

1997-01-01

Discusses recommendations for preparing advanced practice nurses (APNs) to implement guidelines of a health curriculum: (1) ensuring age-appropriate teaching; (2) emphasizing the complex relationships of race/ethnicity, socioeconomic status, and gender; (3) reinforcing the self-care and resilience of adolescents; and (4) examining transitions…

Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study.

PubMed

McCluskey, Annie; Vratsistas-Curto, Angela; Schurr, Karl

2013-08-19

Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005). Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler). Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.

Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study

PubMed Central

2013-01-01

Background Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. Methods A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005). Results Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler). Conclusions Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier. PMID:23958136

The feasibility of implementing recovery, psychosocial and pharmacological interventions for psychosis: comparison study.

PubMed

van der Krieke, Lian; Bird, Victoria; Leamy, Mary; Bacon, Faye; Dunn, Rebecca; Pesola, Francesca; Janosik, Monika; Le Boutillier, Clair; Williams, Julie; Slade, Mike

2015-05-23

Clinical guidelines for the treatment of people experiencing psychosis have existed for over a decade, but implementation of recommended interventions is limited. Identifying influences on implementation may help to reduce this translational gap. The Structured Assessment of Feasibility (SAFE) measure is a standardised assessment of implementation blocks and enablers. The aim of this study was to characterise and compare the implementation blocks and enablers for recommended psychosis interventions. SAFE was used to evaluate and compare three groups of interventions recommended in the 2014 NICE psychosis guideline: pharmacological (43 trials testing 5 interventions), psychosocial (65 trials testing 5 interventions), and recovery (19 trials testing 5 interventions). The 127 trial reports rated with SAFE were supplemented by published intervention manuals, research protocols, trial registrations and design papers. Differences in the number of blocks and enablers across the three interventions were tested statistically, and feasibility profiles were generated. There was no difference between psychosocial and recovery interventions in the number of blocks or enablers to implementation. Pharmacological interventions (a) had fewer blocks than both psychosocial interventions (χ (2)(3) = 133.77, p < 0.001) and recovery interventions (χ (2)(3) = 104.67, p < 0.001) and (b) did not differ in number of enablers from recovery interventions (χ (2)(3) = 0.74, p = 0.863) but had fewer enablers than psychosocial interventions (χ (2)(3) = 28.92, p < 0.001). Potential adverse events associated with the intervention tend to be a block for pharmacological interventions, whereas complexity of the intervention was the most consistent block for recovery and psychosocial interventions. Feasibility profiles show that pharmacological interventions are relatively easy to implement but can sometimes involve risks. Psychosocial and recovery interventions are relatively complex but tend to be more flexible and more often manualised. SAFE ratings can contribute to tackling the current implementation challenges in mental health services, by providing a reporting guideline structure for researchers to maximise the potential for implementation and by informing prioritisation decisions by clinical guideline developers and service managers.

Indication, organization, practical implementation and interpretation guidelines for retrospective CGM recording: A French position statement.

PubMed

Joubert, M; Baillot-Rudoni, S; Catargi, B; Charpentier, G; Esvant, A; Franc, S; Guerci, B; Guilhem, I; Melki, V; Merlen, E; Penfornis, A; Renard, E; Riveline, J P; Schaepelynck, P; Sola-Gazagnes, A; Hanaire, H

2015-12-01

The benefits of retrospective continuous glucose monitoring (retroCGM) recording have been widely explored in clinical studies, and many diabetes physicians routinely use this examination. However, the method of interpretation of CGM recordings has never been precisely described. An expert French panel of physicians met for two days to discuss several aspects of retroCGM use and to produce a position statement. The guidelines cover the indications for retroCGM, the general organization and practical implementation of CGM recordings, a description of the different devices available and guidelines for the interpretation of retroCGM recordings. This consensus document should help clinicians in the proper use of retroCGM. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Feasibility of modified surviving sepsis campaign guidelines in a resource-restricted setting based on a cohort study of severe S. aureus sepsis [corrected].

PubMed

Mahavanakul, Weera; Nickerson, Emma K; Srisomang, Pramot; Teparrukkul, Prapit; Lorvinitnun, Pichet; Wongyingsinn, Mingkwan; Chierakul, Wirongrong; Hongsuwan, Maliwan; West, T Eoin; Day, Nicholas P; Limmathurotsakul, Direk; Peacock, Sharon J

2012-01-01

The Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting. We undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis. It is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.

A theory-based evaluation of a dissemination intervention to improve childcare cooks' intentions to implement nutritional guidelines on their menus.

PubMed

Yoong, Sze Lin; Jones, Jannah; Marshall, Josephine; Wiggers, John; Seward, Kirsty; Finch, Meghan; Fielding, Alison; Wolfenden, Luke

2016-07-25

Childcare services represent a key setting to implement nutritional interventions to support the development of healthy eating behaviours in young children. Childcare-specific nutritional guidelines outlining recommendations for provision of food in care have been developed. Despite this, research suggests that few childcare services currently implement these guidelines. This study aimed to examine the impact of providing printed educational materials on childcare service cooks' intentions to use nutritional guidelines and provide fruit and vegetables on their menu. A randomised controlled trial was conducted with 77 childcare services (38 control and 39 intervention). Intervention service cooks were mailed a two-page educational material together with a menu planning checklist. Intervention development and evaluation was guided by the theory of planned behaviour. Outcome data assessing intentions to use nutritional guidelines and serves of fruit and vegetables provided on menus (primary outcomes) as well as secondary outcomes (attitudes, behavioural regulation and social norms) were collected via a telephone interview with cooks. Relative to the comparison group, cooks in the intervention arm had significantly higher intentions to use the guidelines (p value 0.0005), accompanied by significant changes in perceived behavioural control (p value 0.0008) and attitudes (p value 0.0071). No significant difference in serves of fruit (p value 0.7278) and vegetables (p value 0.0573) was observed. The use of educational materials can improve childcare service cooks' intentions to use nutritional guidelines; however, as a standalone strategy, it may not improve provision of food on menus.

A computerized clinical decision support system as a means of implementing depression guidelines.

PubMed

Trivedi, Madhukar H; Kern, Janet K; Grannemann, Bruce D; Altshuler, Kenneth Z; Sunderajan, Prabha

2004-08-01

The authors describe the history and current use of computerized systems for implementing treatment guidelines in general medicine as well as the development, testing, and early use of a computerized decision support system for depression treatment among "real-world" clinical settings in Texas. In 1999 health care experts from Europe and the United States met to confront the well-documented challenges of implementing treatment guidelines and to identify strategies for improvement. They suggested the integration of guidelines into computer systems that is incorporated into clinical workflow. Several studies have demonstrated improvements in physicians' adherence to guidelines when such guidelines are provided in a computerized format. Although computerized decision support systems are being used in many areas of medicine and have demonstrated improved patient outcomes, their use in psychiatric illness is limited. The authors designed and developed a computerized decision support system for the treatment of major depressive disorder by using evidence-based guidelines, transferring the knowledge gained from the Texas Medication Algorithm Project (TMAP). This computerized decision support system (CompTMAP) provides support in diagnosis, treatment, follow-up, and preventive care and can be incorporated into the clinical setting. CompTMAP has gone through extensive testing to ensure accuracy and reliability. Physician surveys have indicated a positive response to CompTMAP, although the sample was insufficient for statistical testing. CompTMAP is part of a new era of comprehensive computerized decision support systems that take advantage of advances in automation and provide more complete clinical support to physicians in clinical practice.

Systems consultation: protocol for a novel implementation strategy designed to promote evidence-based practice in primary care.

PubMed

Quanbeck, Andrew; Brown, Randall T; E Zgierska, Aleksandra; A Johnson, Roberta; Robinson, James M; Jacobson, Nora

2016-01-27

Adoption of evidence-based practices takes place at a glacial place in healthcare. This research will pilot test an innovative implementation strategy - systems consultation -intended to speed the adoption of evidence-based practice in primary care. The strategy is based on tenets of systems engineering and has been extensively tested in addiction treatment. Three innovations have been included in the strategy - translation of a clinical practice guideline into a checklist-based implementation guide, the use of physician peer coaches ('systems consultants') to help clinics implement the guide, and a focus on reducing variation in practices across prescribers and clinics. The implementation strategy will be applied to improving opioid prescribing practices in primary care, which may help ultimately mitigate the increasing prevalence of opioid abuse and addiction. The pilot test will compare four intervention clinics to four control clinics in a matched-pairs design. A leading clinical guideline for opioid prescribing has been translated into a checklist-based implementation guide in a systematic process that involved experts who wrote the guideline in consultation with implementation experts and primary care physicians. Two physicians with expertise in family and addiction medicine are serving as the systems consultants. Each systems consultant will guide two intervention clinics, using two site visits and follow-up communication by phone and email, to implement the translated guideline. Mixed methods will be used to test the feasibility, acceptability, and preliminary effectiveness of the implementation strategy in an evaluation that meets standards for 'fully developed use' of the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). The clinic will be the primary unit of analysis. The systems consultation implementation strategy is intended to generalize to the adoption of other clinical guidelines. This pilot test is intended to prepare for a large randomized clinical trial that will test the strategy against other implementation strategies, such as audit/feedback and academic detailing, used to close the gap between knowledge and practice. The systems consultation approach has the potential to shorten the famously long time it takes to implement evidence-based practices and clinical guidelines in healthcare.

Pressure ulcers: implementation of evidence-based nursing practice.

PubMed

Clarke, Heather F; Bradley, Chris; Whytock, Sandra; Handfield, Shannon; van der Wal, Rena; Gundry, Sharon

2005-03-01

A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.

Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review.

PubMed

Francke, Anneke L; Smit, Marieke C; de Veer, Anke J E; Mistiaen, Patriek

2008-09-12

Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field. A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews. Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals - e.g., awareness of the existence of the guideline and familiarity with its content - likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines are followed. Finally, environmental characteristics may influence guideline implementation. For example, a lack of support from peers or superiors, as well as insufficient staff and time, appear to be the main impediments. Existing reviews describe various factors that influence whether guidelines are actually used. However, the evidence base is still thin, and future sound research - for instance comparing combinations of implementation strategies versus single strategies - is needed.

Guidelines for the Gamification of Self-Management of Chronic Illnesses: Multimethod Study.

PubMed

AlMarshedi, Alaa; Wills, Gary; Ranchhod, Ashok

2017-05-12

Gamification is the use of game elements and techniques in nongaming contexts. The use of gamification in health care is receiving a great deal of attention in both academic research and the industry. However, it can be noticed that many gamification apps in health care do not follow any standardized guidelines. This research aims to (1) present a set of guidelines based on the validated framework the Wheel of Sukr and (2) assess the guidelines through expert interviews and focus group sessions with developers. Expert interviews (N=6) were conducted to assess the content of the guidelines and that they reflect the Wheel of Sukr. In addition, the guidelines were assessed by developers (N=15) in 5 focus group sessions, where each group had an average of 3 developers. The guidelines received support from the experts. By the end of the sixth interview, it was determined that a saturation point was reached. Experts agreed that the guidelines accurately reflect the framework the Wheel of Sukr and that developers can potentially use them to create gamified self-management apps for chronic illnesses. Moreover, the guidelines were welcomed by developers who participated in the focus group sessions. They found the guidelines to be clear, useful, and implementable. Also, they were able to suggest many ways of gamifying a nongamified self-management app when they were presented with one. The findings suggest that the guidelines introduced in this research are clear, useful, and ready to be implemented for the creation of self-management apps that use the notion of gamification as described in the Wheel of Sukr framework. The guidelines are now ready to be practically tested. Further practical studies of the effectiveness of each element in the guidelines are to be carried out. ©Alaa AlMarshedi, Gary Wills, Ashok Ranchhod. Originally published in JMIR Serious Games (http://games.jmir.org), 12.05.2017.

Barriers to implementing evidence-based clinical guidelines: A survey of early adopters

PubMed Central

Spallek, Heiko; Song, Mei; Polk, Deborah E; Bekhuis, Tanja; Frantsve-Hawley, Julie; Aravamudhan, Krishna

2010-01-01

Objective The purpose of this study is to identify barriers that early-adopting dentists perceive as common and challenging when implementing recommendations from evidence-based (EB) clinical guidelines. Method This is a cross-sectional study. Dentists who attended the 2008 Evidence-based Dentistry Champion Conference were eligible for inclusion. Forty-three dentists (34%) responded to a 22-item questionnaire administered online. Two investigators independently coded and categorized responses to open-ended items. Descriptive statistics were computed to assess the frequency of barriers and perceived challenges. Results The most common barriers to implementation are difficulty in changing current practice model, resistance and criticism from colleagues, and lack of trust in evidence or research. Barriers perceived as serious problems have to do with lack of up-to-date evidence, lack of clear answers to clinical questions, and contradictory information in the scientific literature. Conclusions Knowledge of barriers will help improve translation of biomedical research for dentists. Information in guidelines needs to be current, clear, and simplified for use at chairside; dentists’ fears need to be addressed. PMID:21093800

The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO.

PubMed

Kahan, Natan R; Kahan, Ernesto; Waitman, Dan-Andrei; Kitai, Eliezer; Chintz, David P

2009-09-01

Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians' behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO. The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs' input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention. The test case for this study was the development, dissemination, and implementation of CPG for the treatment of acute uncomplicated cystitis in adult women. Interventions in the form of a lecture at a conference and a letter with personalized feedback were implemented, both individually and combined, to improve physicians' rates of prescribing the first-line drug, nitrofurantoin, and, in the absence of nitrofurantoin, adhering to the recommended duration of three days of treatment with ofloxacin. The tools and data-generating capabilities designed and constructed in Stage I of the project were integral components of all subsequent stages of the program. Personalized feedback alone was sufficient to improve the rate of adherence to the guidelines by 19.4% (95% CI = 16.7, 22.1). This study provides a template for introducing the component of experimentation essential for cultivating an evidence-based culture. This process, composed of collaborative efforts between academic institutions and a managed care organization, may be beneficial to other health care systems.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review.

PubMed

Chen, Chulin; Kan, Ting; Li, Shuang; Qiu, Chen; Gui, Li

2016-12-01

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome. An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes. The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients. The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Opportunities and challenges of resident specialists’ attendance plan guidelines (health-care transformation plan) in Isfahan university hospitals in 2015

PubMed Central

Moradi, Reza; Karimi, Saeid; Yarmohammadian, Mohammad Hossein; Kiaei, Mohammad Zakaria; Mazaheri, Elaheh

2018-01-01

BACKGROUND: Given new reforms in Iran's health-care system and due to the need for gathering evidence regarding the implementation of this plan, this study aimed to investigate opportunities and challenges created by resident specialist attendance plan guidelines in university hospitals. MATERIALS AND METHODS: This study used the qualitative method. Semi-structured interviews were used for data gathering. The study population included all experts of Isfahan University of Medical Science. Sampling was carried out using purposeful sampling method and continued until data saturation was reached. In total, 16 experts were interviewed. Criteria such as “reliability of information,” “trustworthiness,” and “verifiability of the information” were considered. Interviewees were assured that their names would keep hidden and that all information is confidential. Subject analysis method was used for data analysis. RESULTS: The findings of this study based on subject analysis led to extracting three themes in regards of challenges in the implementation of resident (specialist or fellowship) plan in hospitals including structural, management, and resource challenges and one theme in the area of opportunities which were improved quality and timely provision of services. CONCLUSION: The findings showed that despite the strengths of this guideline, there are some fundamental challenges in various areas and need better attention by national level policymakers. These results help health-care policymakers to evaluate the problem with a better attitude and improve the necessary plans for implementation of these guidelines. PMID:29619390

Impact of Implementing National Guidelines on Antibiotic Prescriptions for Acute Respiratory Tract Infections in Pediatric Emergency Departments: An Interrupted Time Series Analysis.

PubMed

Ouldali, Naïm; Bellêttre, Xavier; Milcent, Karen; Guedj, Romain; de Pontual, Loïc; Cojocaru, Bogdan; Soussan-Banini, Valérie; Craiu, Irina; Skurnik, David; Gajdos, Vincent; Chéron, Gérard; Cohen, Robert; Alberti, Corinne; Angoulvant, François

2017-10-16

Many antibiotics are prescribed inappropriately in pediatric emergency departments (PEDs), but little data are available in these settings about effective interventions based on guidelines that follow the antimicrobial stewardship principle. Our aim was to assess the impact of implementing the 2011 national guidelines on antibiotic prescriptions for acute respiratory tract infection (ARTI) in PEDs. We conducted a multicentric, quasiexperimental, interrupted time series analysis of prospectively collected electronic data from 7 French PEDs. We included all pediatric patients who visited a participating PED during the study period from November 2009 to October 2014 and were diagnosed with an ARTI. The intervention consisted of local protocol implementation, education sessions, and feedback. The main outcome was the antibiotic prescription rate of discharge prescriptions for ARTI per 1000 PED visits before and after implementation, analyzed using the segmented regression model. We included 242534 patients with an ARTI. The intervention was associated with a significant change in slope for the antibiotic prescription rate per 1000 PED visits (-0.4% per 15-day period, P = .04), and the cumulative effect at the end of the study was estimated to be -30.9%, (95% CI [-45.2 to -20.1]), representing 13136 avoided antibiotic prescriptions. The broad-spectrum antibiotic prescription relative percentage decreased dramatically (-62.7%, 95% CI [-92.8; -32.7]) and was replaced by amoxicillin. Implementation of the 2011 national French guidelines led to a significant decrease in the antibiotic prescription rate for ARTI and a dramatic drop in broad-spectrum antibiotic prescriptions, in favor of amoxicillin. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

Implementation guideline for non-freeway centerline rumble strips.

DOT National Transportation Integrated Search

2015-03-01

This document presents a guideline for the : implementation of non-freeway centerline rumble : strips on high speed rural highways. It includes : recommended practices, according to MDOT : standards, and describes effective strategies and : technique...

A Process Evaluation of Project Developmental Continuity, Interim Report VII, Volume 1: Findings from the PDC Implementation Study.

ERIC Educational Resources Information Center

Smith, Allen G.; And Others

This third year interim report, one of a series of documents on the evaluation of Project Developmental Continuity (PDC), presents findings from three major analyses of program implementation; measurement of the extent each program has implemented the basic PDC Guidelines; a description of patterns of that implementation; and analysis of some…

Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project.

PubMed

Zgierska, Aleksandra E; Vidaver, Regina M; Smith, Paul; Ales, Mary W; Nisbet, Kate; Boss, Deanne; Tuan, Wen-Jan; Hahn, David L

2018-06-05

Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project. A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system's "routine rollout" method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention. Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities.

Barriers to Implementation of Recommendations for Transport of Children in Ground Ambulances.

PubMed

Woods, Rashida H; Shah, Manish; Doughty, Cara; Gilchrest, Anthony

2017-10-16

The National Highway Traffic Safety Administration (NHTSA) released draft recommendations in 2010 on the safe transport of children in ground ambulances. The purpose of this study was to assess awareness of these guidelines among emergency medical service (EMS) agencies and to identify implementation barriers. We conducted a cross-sectional, anonymous online survey of 911-responding, ground transport EMS agencies in Texas. Demographics, modes of transport based on case scenarios, and barriers to implementation were assessed. Of 62 eligible EMS agencies that took the survey, 35.7% were aware of the NHTSA guidelines, 62.5% agreed they would improve safety, and 41.1% planned to implement them. Seventy-five percent of EMS agencies used the ideal or acceptable alternative to transport children requiring continuous monitoring, and 69.5% chose ideal or acceptable alternatives for children requiring spinal immobilization. The ideal or acceptable alternative was not chosen for children who were not injured or ill (93.2%), ill or injured but not requiring continuous monitoring (53.3%), and situations when multiple patients required transport (57.6%). The main requirements for implementation were provider education, ambulance interior modifications, new guidelines in the EMS agency, and purchase of new equipment. Few EMS agencies are aware of the NHTSA guidelines on safe transport of children in ground ambulances. Although most agencies appropriately transport children who require monitoring, interventions, or spinal immobilization, they use inappropriate means to transport children in situations with multiple patients, lack of injury or illness, or lack of need for monitoring.

New NSLP guidelines: challenges and opportunities for nutrition education practitioners and researchers.

PubMed

Byker, Carmen J; Pinard, Courtney A; Yaroch, Amy L; Serrano, Elena L

2013-01-01

The recent revisions of the National School Lunch Program (NSLP) requirements are designed to align with the 2010 Dietary Guidelines for Americans. The introduction and implementation of the new NSLP has been received with positive and negative reactions from school food professionals, students, parents, and teachers. To promote student health, this is an important time for policy makers, practitioners, and researchers to implement and evaluate strategies to support the new NSLP guidelines. The purpose of this viewpoint was to outline the new NSLP guidelines and discuss challenges and opportunities for implementation, strategies for practice, and future research questions. Copyright © 2013 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke.

PubMed

Otterman, Nicoline; Veerbeek, Janne; Schiemanck, Sven; van der Wees, Philip; Nollet, Frans; Kwakkel, Gert

2017-07-01

To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke. In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline. A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments. The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients. Implications for Rehabilitation The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation. The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients' needs and the degree of priority of the affected ICF category. Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: 'Training on the job' and 'peer assessment in clinical situations'.

Review article: the role of practice guidelines and evidence-based medicine in perioperative patient safety.

PubMed

Crosby, Edward

2013-02-01

The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety. The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue. Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.

Assessing implementation difficulties in tobacco use prevention and cessation counselling among dental providers

PubMed Central

2011-01-01

Background Tobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains. Methods A 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature. Results Internal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, α = 0.86), capability (13.3% of variance, α = 0.83), and opportunity (10.0% of variance, α = 0.71). Conclusions This study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions. PMID:21615948

Linking Portfolio Development to Clinical Supervision: A Case Study.

ERIC Educational Resources Information Center

Zepeda, Sally J.

2002-01-01

Describes a model for portfolio supervision based on the results of a 2-year study of one elementary school's experience in implementing portfolio supervision. Includes four propositions that guided the development of the model. Describes the skills inherent in portfolio supervision. Provides general guidelines for implementation of the portfolio…

Study to determine potential flight applications and human factors design guidelines for voice recognition and synthesis systems

NASA Astrophysics Data System (ADS)

White, R. W.; Parks, D. L.

1985-07-01

A study was conducted to determine potential commercial aircraft flight deck applications and implementation guidelines for voice recognition and synthesis. At first, a survey of voice recognition and synthesis technology was undertaken to develop a working knowledge base. Then, numerous potential aircraft and simulator flight deck voice applications were identified and each proposed application was rated on a number of criteria in order to achieve an overall payoff rating. The potential voice recognition applications fell into five general categories: programming, interrogation, data entry, switch and mode selection, and continuous/time-critical action control. The ratings of the first three categories showed the most promise of being beneficial to flight deck operations. Possible applications of voice synthesis systems were categorized as automatic or pilot selectable and many were rated as being potentially beneficial. In addition, voice system implementation guidelines and pertinent performance criteria are proposed. Finally, the findings of this study are compared with those made in a recent NASA study of a 1995 transport concept.

Study to determine potential flight applications and human factors design guidelines for voice recognition and synthesis systems

NASA Technical Reports Server (NTRS)

White, R. W.; Parks, D. L.

1985-01-01

A study was conducted to determine potential commercial aircraft flight deck applications and implementation guidelines for voice recognition and synthesis. At first, a survey of voice recognition and synthesis technology was undertaken to develop a working knowledge base. Then, numerous potential aircraft and simulator flight deck voice applications were identified and each proposed application was rated on a number of criteria in order to achieve an overall payoff rating. The potential voice recognition applications fell into five general categories: programming, interrogation, data entry, switch and mode selection, and continuous/time-critical action control. The ratings of the first three categories showed the most promise of being beneficial to flight deck operations. Possible applications of voice synthesis systems were categorized as automatic or pilot selectable and many were rated as being potentially beneficial. In addition, voice system implementation guidelines and pertinent performance criteria are proposed. Finally, the findings of this study are compared with those made in a recent NASA study of a 1995 transport concept.

American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery.

PubMed

Froehlich, James B; Karavite, Dean; Russman, Pamela L; Erdem, Nurum; Wise, Chris; Zelenock, Gerald; Wakefield, Thomas; Stanley, James; Eagle, Kim A

2002-10-01

Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. The use of preoperative stress testing (88% to 47%; P <.00001), cardiac catheterization (24% to 11%; P <.05), and coronary revascularization (25% to 2%; P <.00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P <.0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P =.29) but lower for patients at low risk after guideline implementation (31% versus 61%; P =.003). Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.

Using guidelines to improve neonatal health in China and Vietnam: a qualitative study.

PubMed

Raven, Joanna; Liu, Xiaoyun; Hu, Dan; Zhu, Weiming; Hoa, Dinh Thi Phuong; Thi, Le Minh; Duong, Doan Thi Thuy; Alonso-Garbayo, Alvaro; Martineau, Tim

2016-11-11

Neonatal health (NH) remains a major problem in many countries. Children dying before 28 days often suffer from conditions that are preventable or treatable with proven, cost-effective interventions. The knowledge gaps are no longer about what should be done, but to understand why guidelines including these interventions are not followed. Using a behaviour change framework, this study explores neonatal health guidelines use and the role of management in supporting effective usage in two rural settings in China and Vietnam. Semi-structured interviews with policy makers, health care managers and providers (n = 49) and focus group discussions with women, husbands and grandmothers who had experienced maternal and NH care services within the last year (n = 7) were conducted. Data were analysed using the framework approach. Guidelines are not readily available at county, township and village levels in the study sites in China, whereas, in Vietnam, guidelines are available, accepted and being used at facility level. Improvements in implementation could be made in both settings. Factors influencing guidelines use common to both settings included: lack of equipment and supplies; shortage of staff with NH care experience; and guidelines not in line with patient practices. Factors specific to China included: poor guidelines dissemination; and disagreement with guidelines. There was limited community engagement in NH services in China, whereas in Vietnam, community members were actively involved in decision making and provision of services. Managers have an important role in supporting NH guidelines use through: ensuring guidelines are available; allocating appropriate resources; supporting and monitoring staff in their use; and engaging with local communities to promote effective practices. Engaging managers to support implementation is crucial. Management systems that provide the necessary resources, competent staff, and monitoring, regulatory and incentive frameworks as well as community engagement are needed to promote adoption of guidelines. Further research on how best to strengthen local level management so that they tailor interventions to support guideline use to their specific context is needed. This will ensure that proven interventions to address NH problems are used, and that countries move closer to achieving the new Sustainable Development Goal 3 target.

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

PubMed Central

Tistad, Malin; Palmcrantz, Susanne; Wallin, Lars; Ehrenberg, Anna; Olsson, Christina B.; Tomson, Göran; Holmqvist, Lotta Widén; Gifford, Wendy; Eldh, Ann Catrine

2016-01-01

Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations. PMID:27694661

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness.

PubMed

Tistad, Malin; Palmcrantz, Susanne; Wallin, Lars; Ehrenberg, Anna; Olsson, Christina B; Tomson, Göran; Holmqvist, Lotta Widén; Gifford, Wendy; Eldh, Ann Catrine

2016-04-11

Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations. © 2016 by Kerman University of Medical Sciences

Coordinated, Collaborative and Coherent: Developing and Implementing E-Learning Guidelines within a National Tertiary Education System

ERIC Educational Resources Information Center

Suddaby, Gordon; Milne, John

2008-01-01

Purpose: The paper aims to discusses two complementary initiatives focussed on developing and implementing e-learning guidelines to support good pedagogy in e-learning practice. Design/methodology/approach: The first initiative is the development of a coherent set of open access e-learning guidelines for the New Zealand tertiary sector. The second…

The Pupil Nondiscrimination Guidelines for Athletics. Implementing Section 118.13 of the Wisconsin Statutes and PI 9 of the Wisconsin Administrative Code. Revised.

ERIC Educational Resources Information Center

Wisconsin Interscholastic Athletic Association.

This guide is designed to assist schools in fully implementing Wisconsin's pupil nondiscrimination guidelines which provide equal educational opportunity for all of its students. The guidelines focus on discrimination problems in interscholastic athletics and are based on sex equity. Following a foreword and acknowledgements, the document is…

36 CFR Exhibit B to Part 906 - Guidelines for Establishing Strategy To Implement Affirmative Action Personnel Plan

Code of Federal Regulations, 2011 CFR

2011-07-01

... Strategy To Implement Affirmative Action Personnel Plan B Exhibit B to Part 906 Parks, Forests, and Public Property PENNSYLVANIA AVENUE DEVELOPMENT CORPORATION AFFIRMATIVE ACTION POLICY AND PROCEDURE Pt. 906, Exh. B Exhibit B to Part 906—Guidelines for Establishing Strategy To Implement Affirmative Action...

DOT report for implementing OMB's information dissemination quality guidelines

DOT National Transportation Integrated Search

2002-08-01

Consistent with The Office of : Management and Budgets (OMB) Guidelines (for Ensuring and Maximizing the Quality, : Objectivity, Utility, and Integrity of Information Disseminated by Federal Agencies) : implementing Section 515 of the Treasury and...

Synopsis and Review of the American College of Cardiology Foundation/American Heart Association 2013 ST-Elevation Myocardial Infarction Guideline.

PubMed

Brown, Helen F

2014-01-01

The "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines" is a major revision of the 2004 guideline. This article provides a synopsis and review of the guideline focusing on changes in patient care and implementing processes to ensure quality care. The implementation of this guideline provides nursing with a unique opportunity to affect patients and families primarily by recognition of the event and education about lifestyle modification and disease management. Regionalization of emergency systems provides a novel situation for nursing to develop interdepartmental and system protocols.

Implementation of a multidisciplinary guideline improves preterm infant admission temperatures.

PubMed

Harer, M W; Vergales, B; Cady, T; Early, A; Chisholm, C; Swanson, J R

2017-11-01

Hypothermia is a common problem in preterm infants immediately following delivery.Local problem:The rate of admission hypothermia in our neonatal intensive care unit (NICU) was above the rate of comparable NICUs in the Vermont Oxford Network. To reduce the rate of preterm admission hypothermia, a quality improvement (QI) project was implemented, utilizing the plan-do-study-act (PDSA) methodology. A guideline for delivery room thermoregulation management in <35-week infants at the University of Virginia was created and put into practice by a multidisciplinary team. Clinical practice changes in the guideline included: increasing operating room temperatures, obtaining a 10-min axillary temperature, using an exothermic mattress for all infants <35 weeks, and using a polyethylene wrap for infants <32 weeks. The baseline rate of hypothermia (<36.5 °CC) was 63%. Three PDSA cycles data were completed on 168 consecutive preterm births. The post-implementation rate of hypothermia (<36.5 °C) was reduced to 30% (P<0.001). The incidence of moderate hypothermia (< 36 °C) was reduced from a baseline of 29% to a rate of 9% (P<0.001). Use of a multidisciplinary guideline to increase preterm NICU admission temperatures resulted in a decrease in hypothermic infants.

Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee.

PubMed

Brand, C; Cox, S

2006-03-01

Effective implementation of evidence-based care has been associated with better health outcomes; however, evidence-based clinical practice guidelines have been used with varying success. This study aimed to develop integrative tools to support implementation of best practice recommendations for nonsurgical management of osteoarthritis (OA) of the hip and knee and to identify barriers to effective implementation. Published, peer reviewed clinical practice guidelines were updated and translated into an OA care pathway. Key decision nodes in the pathway were identified by a Multidisciplinary Working Group. Qualitative research methods were used to inform pathway development and to identify barriers and enablers for pathway implementation. Qualitative components included purposively selected stakeholder focus groups, key informant interviews and patient process mapping of 10 patient journeys in different settings over a 3-month period. All interviews, facilitated by a trained project officer, were semistructured, recorded, then thematically analysed and summarized. An OA care pathway, clinician and patient toolkits were developed that met the needs of multidisciplinary end-users. Several system- and setting-specific barriers to pathway implementation were identified. Opportunities to improve patient access, interprofessional communication, patient information and education and continuity of care processes were identified. Integrative tools for implementation of best evidence care for patients with OA of the hip and knee were tailored to end-user needs and preferences. Multiple barriers exist that potentially limit effective implementation of best evidence. Comprehensive assessment of barriers and enablers to effective guideline or pathway implementation is recommended before implementation and evaluation.

A Case Study of the Implementation of Chinese Kindergarten Mathematics Curriculum

ERIC Educational Resources Information Center

Hu, Bi Ying; Fuentes, Sarah Quebec; Wang, Chun Yan; Ye, Feiwei

2014-01-01

In 2001, the Chinese Ministry of Education issued Guidelines for Preschool Education (GPE) (trial version) to call on early childhood practitioners to use a child-centered and play-based approach to teaching and learning. The guidelines also include mathematics within the science domain and described its standards in a way that significantly…

Implementation of American Academy of Pediatrics guidelines for palivizumab prophylaxis in a pediatric hospital.

PubMed

Zembles, Tracy N; Gaertner, Katherine M; Gutzeit, Michael F; Willoughby, Rodney E

2016-03-15

One hospital's implementation of revised American Academy of Pediatrics (AAP) guidelines for palivizumab prophylaxis of respiratory syncytial virus (RSV) infection is described. Revised AAP guidelines for RSV prophylaxis in infants and young children at increased risk for RSV infection recommend that up to five doses of palivizumab be administered during the RSV season. The guidelines also recommend that inpatients not receive monthly palivizumab prophylaxis and that infants and young children eligible for prophylaxis during the RSV season receive a dose of palivizumab two or three days before discharge or promptly after discharge. To ensure compliance with the revised AAP guidelines, a 296-bed hospital implemented a quality-improvement project including (1) efforts by the antimicrobial stewardship pharmacist and the chief medical officer to notify and educate healthcare providers regarding institutional adoption of the guidelines, (2) reinforcement of guideline adherence by clinical pharmacists during daily bedside rounds and via prospective review of all palivizumab orders, and (3) a medication-use evaluation (MUE) to assess adherence to the guidelines. The MUE results showed that during the 2014-15 RSV season (after implementation of the practice changes), the number of palivizumab doses administered at the hospital declined by 56% from the previous RSV season, with 97% of doses administered for appropriate indications. Standardized, comprehensive guidelines with defined criteria for palivizumab prophylaxis of RSV infection resulted in $303,227 of cost savings without a discernible change in nosocomial transmission, or morbidity, or mortality. Hospital infection-control practices controlled nosocomial RSV transmission. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Applicability and accuracy of pretest probability calculations implemented in the NICE clinical guideline for decision making about imaging in patients with chest pain of recent onset.

PubMed

Roehle, Robert; Wieske, Viktoria; Schuetz, Georg M; Gueret, Pascal; Andreini, Daniele; Meijboom, Willem Bob; Pontone, Gianluca; Garcia, Mario; Alkadhi, Hatem; Honoris, Lily; Hausleiter, Jörg; Bettencourt, Nuno; Zimmermann, Elke; Leschka, Sebastian; Gerber, Bernhard; Rochitte, Carlos; Schoepf, U Joseph; Shabestari, Abbas Arjmand; Nørgaard, Bjarne; Sato, Akira; Knuuti, Juhani; Meijs, Matthijs F L; Brodoefel, Harald; Jenkins, Shona M M; Øvrehus, Kristian Altern; Diederichsen, Axel Cosmus Pyndt; Hamdan, Ashraf; Halvorsen, Bjørn Arild; Mendoza Rodriguez, Vladimir; Wan, Yung Liang; Rixe, Johannes; Sheikh, Mehraj; Langer, Christoph; Ghostine, Said; Martuscelli, Eugenio; Niinuma, Hiroyuki; Scholte, Arthur; Nikolaou, Konstantin; Ulimoen, Geir; Zhang, Zhaoqi; Mickley, Hans; Nieman, Koen; Kaufmann, Philipp A; Buechel, Ronny Ralf; Herzog, Bernhard A; Clouse, Melvin; Halon, David A; Leipsic, Jonathan; Bush, David; Jakamy, Reda; Sun, Kai; Yang, Lin; Johnson, Thorsten; Laissy, Jean-Pierre; Marcus, Roy; Muraglia, Simone; Tardif, Jean-Claude; Chow, Benjamin; Paul, Narinder; Maintz, David; Hoe, John; de Roos, Albert; Haase, Robert; Laule, Michael; Schlattmann, Peter; Dewey, Marc

2018-03-19

To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. • Duke clinical score is not implemented correctly in NICE guideline 95. • Pretest probability assessment in NICE guideline 95 is impossible for most patients. • Improved clinical decision making requires accurate pretest probability calculation. • These refinements are essential for appropriate use of cardiac CT.

Multifaceted implementation of stroke prevention guidelines in primary care: cluster‐randomised evaluation of clinical and cost effectiveness

PubMed Central

Wright, John; Bibby, John; Eastham, Joe; Harrison, Stephen; McGeorge, Maureen; Patterson, Chris; Price, Nick; Russell, Daphne; Russell, Ian; Small, Neil; Walsh, Matt; Young, John

2007-01-01

Objective To evaluate clinical and cost effectiveness of implementing evidence‐based guidelines for the prevention of stroke. Design Cluster‐randomised trial Setting Three primary care organisations in the North of England covering a population of 400 000. Participants Seventy six primary care teams in four clusters: North, South & West, City I and City II. Intervention Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack (TIA) were developed and implemented using a multifaceted approach including evidence‐based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits. Outcomes Identification and appropriate treatment of patients with atrial fibrillation or TIA, and cost effectiveness. Results Implementation led to 36% increase (95% CI 4% to 78%) in diagnosis of atrial fibrillation, and improved treatment of TIA (odds ratio of complying with guidelines 1.8; 95% CI 1.1 to 2.8). Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater (OR 1.46 95% CI 1.10 to 1.94) in the condition for which practices had received the implementation programme. The development and implementation of guidelines cost less than £1500 per practice. The estimated costs per quality‐adjusted life year gained by patients with atrial fibrillation or TIA were both less than £2000, very much less than the usual criterion for cost effectiveness. Conclusions Implementation of evidence‐based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention was feasible and very cost effective. Key components of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication and use of established networks and opinion leaders. PMID:17301206

Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness.

PubMed

Wright, John; Bibby, John; Eastham, Joe; Harrison, Stephen; McGeorge, Maureen; Patterson, Chris; Price, Nick; Russell, Daphne; Russell, Ian; Small, Neil; Walsh, Matt; Young, John

2007-02-01

To evaluate clinical and cost effectiveness of implementing evidence-based guidelines for the prevention of stroke. Cluster-randomised trial Three primary care organisations in the North of England covering a population of 400,000. Seventy six primary care teams in four clusters: North, South & West, City I and City II. Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack (TIA) were developed and implemented using a multifaceted approach including evidence-based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits. Identification and appropriate treatment of patients with atrial fibrillation or TIA, and cost effectiveness. Implementation led to 36% increase (95% CI 4% to 78%) in diagnosis of atrial fibrillation, and improved treatment of TIA (odds ratio of complying with guidelines 1.8; 95% CI 1.1 to 2.8). Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater (OR 1.46 95% CI 1.10 to 1.94) in the condition for which practices had received the implementation programme. The development and implementation of guidelines cost less than 1500 pounds per practice. The estimated costs per quality-adjusted life year gained by patients with atrial fibrillation or TIA were both less than 2000 pounds, very much less than the usual criterion for cost effectiveness. Implementation of evidence-based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention was feasible and very cost effective. Key components of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication and use of established networks and opinion leaders.

Clinical trials and the new good clinical practice guideline in Japan. An economic perspective.

PubMed

Ono, S; Kodama, Y

2000-08-01

Japanese clinical trials have been drastically changing in response to the implementation of the International Conference on Harmonisation-Good Clinical Practice (ICH-GCP) guideline in 1997. The most important aim of the new guideline is to standardise the quality of clinical trials in the US, European Union and Japan, but it inevitably imposes substantial costs on investigators, sponsors and even patients in Japan. The study environment in Japan differs from that in the US in several ways: (i) historical lack of a formal requirement for informed consent; (ii) patients' attitudes to clinical trials in terms of expectation of positive outcomes; (iii) the implications of universal health insurance for trial participation; (iv) the historical absence of on-site monitoring by the sponsor, with the attendant effects on study quality; and (v) the lack of adequate financial and personnel support for the conduct of trials. Implementation of the new GCP guideline will improve the ethical and scientific quality of trials conducted in Japan. It may also lead to an improved relationship between medical professionals and patients if the requirement for explicit informed consent in clinical trials leads to the provision of a similar level of patient information in routine care and changes the traditional paternalistic attitude of physicians to patients. The initial response of the Japanese 'market' for clinical trials to the implementation of the ICH-GCP guideline has been clinical trial price increases and a decrease in the number of study contracts. These changes can be explained by applying a simple demand-supply scheme. Whether clinical trials undertaken in Japan become more or less attractive to the industry in the long term will depend on other factors such as international regulations on the acceptability of foreign clinical trials and the reform of domestic healthcare policies.

Policy at play: The implementation of Healthy Eating and Active Living Guidelines in municipal child care settings.

PubMed

McKay, Kelly; Nigro, Sherry

2017-03-01

In 2012, Ottawa Public Health (OPH) partnered with the City of Ottawa Municipal Child Care (MCC) Services to develop Healthy Eating and Active Living (HEAL) Guidelines. The Guidelines aim to promote consistent standards of practice in child care settings related to healthy environments and food, physical activity, physical literacy, decreased sedentary behaviours, and positive role modeling by staff. The Guidelines targeted 498 children aged 18 months to 5 years, attending MCC centres. Resources and training were provided to 10 supervisors, 63 child care educators and 9 cooks. Components of the Guidelines were piloted in 5 MCC sites prior to being launched in 10 MCC sites across Ottawa, Ontario. Two project Advisory Groups supported the development of the Guidelines. Staff training, resources, recipes and menus were provided. An evaluation was conducted and has informed the Guidelines' subsequent community implementation. In 2015, accompanying web-based resources and e-modules were developed. The evaluation demonstrated environmental and programming changes. Parent satisfaction was high and preliminary findings showed no real changes in food costs. Following implementation, the cooks reported high compliance to the 6-week menu plans provided, and the number of sites offering 120 minutes or more of daily physical activity increased. Through novel intersectoral partnerships, OPH was able to implement and evaluate HEAL Guidelines in tandem. The interdisciplinary project Advisory Groups, training of cooks, and engagement of the Ontario Coaches Association were all innovative elements of this project and may influence future public health activity in this area.

The impact of evidence-based sepsis guidelines on emergency department clinical practice: a pre-post medical record audit.

PubMed

Romero, Bernadine; Fry, Margaret; Roche, Michael

2017-11-01

To explore the number of patients presenting with sepsis before and after guideline implementation; the impact of sepsis guidelines on triage assessment, emergency department management and time to antibiotics. Sepsis remains one of the leading causes of mortality and morbidity within hospitals. Globally, strategies have been implemented to reduce morbidity and mortality rates, which rely on the early recognition and management of sepsis. To improve patient outcomes, the New South Wales government in Australia introduced sepsis guidelines into emergency departments. However, the impact of the guidelines on clinical practice remains unclear. A 12-month pre-post retrospective randomised medical record audit of adult patients with a sepsis diagnosis. Data were extracted from the emergency department database and paper medical record. Data included patient demographic (age, gender), clinical information (time of arrival, triage code, seen by time, disposition, time to antibiotic, pathology, time to intravenous fluids) and patient assessment data (heart rate, respiratory rate, blood pressure, temperature, oxygen saturations, medication). This study demonstrated a statistically significant 230-minute reduction in time to antibiotics post implementation of the guidelines. The post group (n = 165) received more urgent triage categories (n = 81; 49·1%), a 758-minute reduction in mean time to second litre of intravenous fluids and an improvement in collection of lactate (n = 112, 67·9%), also statistically significant. The findings highlight the impact the guidelines can have on clinician decision-making and behaviour that support best practice and positive patient outcomes. The sepsis guidelines improved the early assessment, recognition and management of patients presenting with sepsis in one tertiary referral emergency department. The use of evidenced-based guidelines can impact clinical decision-making and behaviour, resulting in the translation and support of best practice and improving patient care. © 2017 John Wiley & Sons Ltd.

Improved survival with an innovative approach to the treatment of severely burned patients: development of a burn treatment manual.

PubMed

Morisada, S; Nosaka, N; Tsukahara, K; Ugawa, T; Sato, K; Ujike, Y

2015-09-30

The management of severely burned patients remains a major issue worldwide as indicated by the high incidence of permanent debilitating complications and poor survival rates. In April 2012, the Advanced Emergency & Critical Care Medical Center of the Okayama University Hospital began implementing guidelines for severely burned patients, distributed as a standard burn treatment manual. The protocol, developed in-house, was validated by comparing the outcomes of patients with severe extensive burns (SEB) treated before and after implementation of these new guidelines at this institution. The patients included in this study had a burn index (BI) ≥30 or a prognostic burn index (PBI = BI + patient's age) ≥100. The survival rate of the patients with BI ≥30 was 65.2% with the traditional treatment and 100% with the new guidelines. Likewise, the survival rate of the patients with PBI ≥100 was 61.1% with the traditional treatment compared to 100% with the new guidelines. Together, these data demonstrate that the new treatment guidelines dramatically improved the treatment outcome and survival of SEB patients.

Feasibility of encoding the Institute for Clinical Systems Improvement Depression Guideline using the Omaha System.

PubMed

Monsen, Karen A; Neely, Claire; Oftedahl, Gary; Kerr, Madeleine J; Pietruszewski, Pam; Farri, Oladimeji

2012-08-01

Evidence-based clinical guidelines are being developed to bridge the gap between research and practice with the goals of improving health care quality and population health. However, disseminating, implementing, and ensuring ongoing use of clinical guidelines in practice settings is challenging. The purpose of this study was to demonstrate the feasibility of encoding evidence-based clinical guidelines using the Omaha System. Clinical documentation with Omaha System-encoded guidelines generates individualized, meaningful data suitable for program evaluation and health care quality research. The use of encoded guidelines within the electronic health record has potential to reinforce use of guidelines, and thus improve health care quality and population health. Research using Omaha System data generated by clinicians has potential to discover new knowledge related to guideline use and effectiveness. Copyright © 2012 Elsevier Inc. All rights reserved.

Anesthesiologists' familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting.

PubMed

Nurok, Michael; Green, Douglas S T; Chisholm, Mary F; Fins, Joseph J; Liguori, Gregory A

2014-05-01

To assess anesthesiologists' familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Advance Directives in the perioperative setting. Single-center, 4-question anonymous survey. Urban academic medical center. Up to 34 subjects responded to each question. Familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting ranged from 45% to 100%. There was inadequate familiarity with components of the ASA and ACS guidelines on advance directives in the perioperative setting. Larger studies are required to assess anesthesiologists' familiarity with national society guidelines that directly affect patient care. Future work should investigate best practices for guideline implementation, and consequences of poor adherence to national guidelines. Copyright © 2014 Elsevier Inc. All rights reserved.

Incidence of infection after Mohs micrographic and dermatologic surgery before and after implementation of new sterilization guidelines.

PubMed

Liu, Austin; Lawrence, Naomi

2014-06-01

Clinical guidelines regarding surgical instrument sterilization established by accrediting organizations should be based on peer-reviewed scientific literature. Few data exist in the scientific literature to support the changes in sterilization protocols imposed by accrediting organizations. We sought to determine whether recently established guidelines for the sterilization of surgical instruments have had any clinical impact on postsurgical infection rates. Infections rates after excisional and Mohs micrographic surgery before and after implementation of new Joint Commission on the Accreditation of Healthcare Organizations sterilization guidelines were examined retrospectively. All surgeries were performed at an academic outpatient office. In all, 1415 patients underwent a total of 1688 surgeries. No significant differences were observed in mean patient age (P = .113), mean number of Mohs micrographic surgical levels (P = .067), final defect size (P = .305), patient gender (P = .072), repair type (P = .691), or infection rate (P = .453). No major differences in predisposing factors were identified in patients who developed postsurgical infections. This was a retrospective study conducted at a single academic institution. In our practice, recent changes in surgical instrument sterilization protocols have had no impact on postsurgical infection rates. The implementation of such guidelines places an additional burden on the health care system without providing any improvement in patient outcomes. Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.

An implementation strategy to improve the guideline adherence of insurance physicians: an experiment in a controlled setting

PubMed Central

2011-01-01

Background The aim of this study was to investigate the efficacy of a newly developed implementation strategy for the insurance medicine guidelines for depression in the Netherlands. We hypothesized that an educational intervention would increase the insurance physicians' (IPs) guideline adherence in a controlled setting. Methods Forty IPs were allocated in a randomised controlled trial (RCT) to an intervention group (IG) (n = 21) and a control group (CG) (n = 19). The IG received tailored training in applying the guidelines for depression, while the CG received an alternative programme. Baseline (T0) and follow-up (T1) measurements were conducted before and after the intervention within a period of two weeks. The intervention consisted of a workshop in which the evidence-based theory of the guidelines was translated for use in practice, with the help of various tools. The IPs had to write a case-report on the basis of video cases, two before and two after the training. Specially trained and blinded test IPs judged the case reports independently on the basis of six performance indicators. Primary outcome measure in the controlled setting of the trial was guideline adherence measured by six performance indicators on a scale of one to seven. Secondary outcome measure was knowledge of the guidelines for depression. Analyses were performed using Linear Mixed Models, and ANCOVA. Results We found significantly higher scores in the IG than in the CG at T1 for both outcomes. The interaction effect (standard error; p-value) of group crossed with time was 0.97 (0.19; p < 0.0005) for guideline adherence in the controlled setting. The group effect at T1 for the knowledge test was 0.86 (0.40; p = 0.038). Conclusions The newly developed implementation strategy for the insurance medicine guidelines for depression improved the guideline adherence of the trained IPs in disability assessments of clients with depression when performed in a controlled setting. Furthermore, the trained IPs showed gains in knowledge of the guidelines for depression. Trial registration Netherlands' Trial Register NTR1863. PMID:22188876

Prevention of venous thromboembolism in hospitalized patients: analysis of reduced cost and improved clinical outcomes.

PubMed

Duff, Jed; Walker, Kim; Omari, Abdullah; Stratton, Charlie

2013-03-01

The impact of implementing a guideline on venous thromboembolism (VTE) prophylaxis was evaluated in a metropolitan private hospital with a before- and after-intervention study. This subsequent study aimed to identify if improved prophylaxis rates translated into cost savings and improved clinical outcomes. A conceptual decision-tree analytical model incorporating local treatment algorithms and clinical trial data was used to compare prophylaxis costs and clinical outcomes before and after the guideline implementation. The study analyzed data from 21,942 medical and surgical patients admitted to a 250-bed acute-care private hospital in Sydney, Australia. The modeled simulation estimated the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as adverse events such as heparin-induced thrombocytopenia (HIT), post-thrombotic syndrome (PTS), major bleeding, and mortality. The costs of prophylaxis therapy and treating adverse events were also calculated. The improvement in prophylaxis rates following the implementation of the guideline was estimated to result in 13 fewer deaths, 84 fewer symptomatic DVTs, 19 fewer symptomatic PEs, and 512 fewer hospital-bed days. Improved adherence to evidence-based prophylaxis regimens was associated with overall cost savings of $245,439 over 12 months. We conclude that improved adherence to evidence-based guidelines for VTE prophylaxis is achievable and is likely to result in fewer deaths, fewer VTE events, and a significant overall cost saving. Copyright © 2013 Society for Vascular Nursing, Inc. Published by Mosby, Inc. All rights reserved.

Barriers and Facilitators for Guidelines with Depression and Anxiety in Parkinson's Disease or Dementia.

PubMed

Goodarzi, Zahra; Hanson, Heather M; Jette, Nathalie; Patten, Scott; Pringsheim, Tamara; Holroyd-Leduc, Jayna

2018-06-01

ABSTRACTOur primary objective was to understand the barriers and facilitators associated with the implementation of high-quality clinical practice guidelines (CPGs) for depression and anxiety in patients with dementia or Parkinson's disease (PD). We conducted focus groups or interviews with participants experiencing dementia or PD, their caregivers, and physicians in Calgary, Alberta, and applied the theoretical domains framework and behaviour change wheel to guide data collection and perform a framework analysis. Thirty-three physicians and seven PD patients/caregivers participated. We report barriers and facilitators to the implementation of guideline recommendations for diagnosis, management, and the use of the guidelines. An overarching theme was the lack of evidence for depression or anxiety disorders in dementia or PD, which was prominent for anxiety versus depression. Patients noted difficulties with communicating symptoms and accessing services. Although guidelines are available, physicians have difficulty implementing certain recommendations due primarily to a lack of evidence regarding efficacy.

Strengthening Geography in the Social Studies. National Council for the Social Studies Bulletin No. 81.

ERIC Educational Resources Information Center

Natoli, Salvatore J., Ed.

This bulletin is an outgrowth of the work of the Geographic Education National Implementation Project (GENIP), whose purpose is to implement the recommendations contained in the National Council for Geographic Education-Association of American Geographers 1984 publication, Guidelines for Geographic Education: Elementary and Secondary Schools. The…

Guidelines for the Implementation of Reduced Lighting on Roadways

DOT National Transportation Integrated Search

2014-06-01

This report provides guidelines for the implementation of an adaptive lighting system for roadway lighting. Based on the analysis of crashes and lighting performance, a series of criteria and the associated design levels have been developed to provid...

Electronic health records in four community physician practices: impact on quality and cost of care.

PubMed

Welch, W Pete; Bazarko, Dawn; Ritten, Kimberly; Burgess, Yo; Harmon, Robert; Sandy, Lewis G

2007-01-01

To assess the impact of the electronic health record (EHR) on cost (i.e., payments to providers) and process measures of quality of care. Retrospective before-after-study-control. From the database of a large managed care organization (MCO), we obtained the claims of patients from four community physician practices that implemented the EHR and from about 50 comparison practices without the EHR in the same counties. The diverse patient and practice populations were chosen to be a sample more representative of typical private practices than has previously been studied. For four chronic conditions, we used commercially-available software to analyze cost per episode over a year and the rate of adherence to clinical guidelines as a measure of quality. The implementation of the EHR had a modest positive impact on the quality measure of guideline adherence for hypertension and hyperlipidemia, but no significant impact for diabetes and coronary artery disease. No measurable impact on the short-term cost per episode was found. Discussions with the study practices revealed that the timing and comprehensiveness of EHR implementation varied across practices, creating an intervention variable that was heterogeneous. Guideline adherence increased across practices without EHRs and slightly faster in practices with EHRs. Measuring the impact of EHRs on cost per episode was challenging, because of the difficulty of completely capturing the long-term episodic costs of a chronic condition. Few practices associated with the study MCO had implemented EHRs in any form, much less utilizing standardized protocols.

A systematic review of implementation strategies to deliver guidelines on obstetric care practice in low- and middle-income countries.

PubMed

Imamura, Mari; Kanguru, Lovney; Penfold, Suzanne; Stokes, Tim; Camosso-Stefinovic, Janette; Shaw, Beth; Hussein, Julia

2017-01-01

Healthcare measures to prevent maternal deaths are well known. However, effective implementation of this knowledge to change practice remains a challenge. To assess whether strategies to promote the use of guidelines can improve obstetric practices in low- and middle-income countries (LMICs). Electronic databases were searched up to February 7, 2014, using relevant terms for implementation strategies (e.g. "audit," "education," "reminder"), and maternal mortality. Randomized and non-randomized studies of implementation strategies targeting healthcare professionals within the formal health services in LMICs were included. Cochrane methodological guidance was followed. Because of heterogeneity in the interventions, a narrative synthesis was completed. Nine studies met the inclusion criteria. Moderate-to-low-quality evidence was found to show improvement in the areas of doctor-patient communication (one study), analgesic provision (one study), the management of emergencies (two studies) and maternal and late neonatal mortality (one study each). Intervention effects were not consistent across studies. Implementation strategies targeting health professionals could lead to improvement in obstetric care in LMICs. Future research should explore what feature of an intervention is effective in one context and how this could be translated into another context. CRD42014010310. © 2016 International Federation of Gynecology and Obstetrics.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review protocol.

PubMed

Tomasone, Jennifer R; Chaudhary, Rushil; Brouwers, Melissa C

2015-08-25

Health care professionals (HCPs) are able to make effective decisions regarding patient care through the use of systematically developed clinical practice guidelines (CPGs). These recommendations are especially important in a cancer health care context as patients are exposed to a multitude of interdisciplinary HCPs offering high-quality care throughout diagnosis, treatment, survivorship and palliative care. Although a large number of CPGs targeted towards cancer are widely disseminated, it is unknown whether implementation strategies targeting the use of these guidelines are effective in effecting HCP behaviour and patient outcomes in the cancer care context. The purpose of this systematic review will be to determine the effectiveness of different CPG dissemination and implementation interventions on HCPs' behaviour and patient outcomes in the cancer health care context. Five electronic databases (CINAHL, the Cochrane Controlled Trials Register, MEDLINE via Ovid, EMBASE via Ovid and PsycINFO via Ovid) will be searched to include all studies examining the dissemination and/or implementation of CPGs in a cancer care setting targeting all HCPs. CPG implementation strategies will be included if the CPGs were systematically developed (e.g. literature review/evidence-informed, expert panel, evidence appraisal). The studies will be limited to randomized controlled trials, controlled clinical trials and quasi-experimental (interrupted time series, controlled before-and-after designs) studies. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. The aim of this review is to inform cancer care health care professionals and policymakers about evidence-based implementation strategies that will allow for effective use of CPGs. PROSPERO CRD42015019331.

Discursive gaps in the implementation of public health policy guidelines in India: the case of HIV testing.

PubMed

Sheikh, Kabir; Porter, John

2010-12-01

The implementation of standardized policy guidelines for care of diseases of public health importance has emerged as a subject of concern in low and middle-income countries (LMIC) globally. We conducted an empirical research study using the interpretive policy analysis approach to diagnose reasons for gaps in the implementation of national guidelines for HIV testing in Indian hospitals. Forty-six in-depth interviews were conducted with actors involved in policy implementation processes in five states of India, including practitioners, health administrators, policy-planners and donors. We found that actors' divergences from their putative roles in implementation were underpinned by their inhabitation of discrete 'systems of meaning' - frameworks for perceiving policy problems, acting and making decisions. Key gaps in policy implementation included conflicts between different actors' ideals of performance of core tasks and conformance with policy, and problems in communicating policy ideas across systems of meaning. These 'discursive' gaps were compounded by the lack of avenues for intellectual intercourse and by unaccounted interrelationships of power between implementing actors. Our findings demonstrate the importance of thinking beyond short-sighted ideals of aligning frontline practices with global policymakers' intentions. Recognising the deliberative nature of implementation, and strengthening discourse and communications between involved actors may be critical to the success of public health policies in Indian and comparable LMIC settings. Effective policy implementation in the long term also necessitates enhancing practitioners' contributions to the policy process, and equipping country public health functionaries to actualize their policy leadership roles. Copyright © 2010 Elsevier Ltd. All rights reserved.

Scientific Reporting: Raising the Standards.

PubMed

McLeroy, Kenneth R; Garney, Whitney; Mayo-Wilson, Evan; Grant, Sean

2016-10-01

This article is based on a presentation that was made at the 2014 annual meeting of the editorial board of Health Education & Behavior. The article addresses critical issues related to standards of scientific reporting in journals, including concerns about external and internal validity and reporting bias. It reviews current reporting guidelines, effects of adopting guidelines, and offers suggestions for improving reporting. The evidence about the effects of guideline adoption and implementation is briefly reviewed. Recommendations for adoption and implementation of appropriate guidelines, including considerations for journals, are provided. © 2016 Society for Public Health Education.

Pediatric Audiology in North America: Current Clinical Practice and How It Relates to the American Academy of Audiology Pediatric Amplification Guideline.

PubMed

Moodie, Sheila; Rall, Eileen; Eiten, Leisha; Lindley, George; Gordey, Dave; Davidson, Lisa; Bagatto, Marlene; Scollie, Susan

2016-03-01

There is broad consensus that screening and diagnosis of permanent hearing loss in children must be embedded within a comprehensive, evidence-based, family-centered intervention program. Clinical practice guidelines (CPGs) for pediatric hearing assessment and hearing aid verification aim to reduce variability in practice and increase the use of effective evidence-based diagnostic and treatment options so that optimal outcomes may be achieved. To be of value, guidelines must be translated and implemented into practice and ongoing monitoring of their use in practice should occur. This paper provides the results of two studies that aim to examine current pediatric audiology and amplification practice in North America. A concurrent embedded mixed methods design was used. An electronic survey was distributed to North American audiologists who delivered pediatric audiology services with 350 audiologists participating in study 1 and 63 audiologists participating in study 2. A quantitative approach was the predominant method of data collection. Respondents were prompted to provide additional qualitative text and detail regarding their quantitative response choice. This qualitative text was used during the analysis phase and combined with quantitative results to assist understanding of respondents' knowledge, skills, and barriers/facilitators to implement best practice in pediatric amplification. Approximately 70% of audiologists reported using best-practice protocols for pediatric hearing aid fitting. Despite widespread knowledge and increased use of CPGs over the last 18 yrs, results of these studies show that variation in practice patterns continue to exist. Several examples of implementation challenges are discussed with recommendations provided. In order for audiologists working with children who are deaf or hard of hearing and their families to achieve the principles of family-centered early intervention, practice guidelines must continue to be developed, disseminated, and translated as they have a positive impact on the services provided. Researchers and clinical audiologists who deliver services must continue to collaborate to understand the "how" and "why" of implementing guidelines into practice and to identify the barriers/facilitators encountered in trying to do so. American Academy of Audiology.

SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study.

PubMed

Melman, Sonja; Schoorel, Ellen N C; Dirksen, Carmen; Kwee, Anneke; Smits, Luc; de Boer, Froukje; Jonkers, Madelaine; Woiski, Mallory D; Mol, Ben Willem J; Doornbos, Johannes P R; Visser, Harry; Huisjes, Anjoke J M; Porath, Martina M; Delemarre, Friso M C; Kuppens, Simone M I; Aardenburg, Robert; Van Dooren, Ivo M A; Vrouenraets, Francis P J M; Lim, Frans T H; Kleiverda, Gunilla; van der Salm, Paulien C M; de Boer, Karin; Sikkema, Marko J; Nijhuis, Jan G; Hermens, Rosella P M G; Scheepers, Hubertina C J

2013-01-03

Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives). An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs. This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child. http://www.clinicaltrials.gov: NCT01261676.

Attitudes Toward Practice Guidelines Among ICU Personnel: A Cross-Sectional Anonymous Survey

PubMed Central

Quiros, Dave; Lin, Susan; Larson, Elaine L

2007-01-01

Objectives To assess attitudes of ICU staff members toward practice guidelines in general and toward a specific guideline, CDC's Guideline for Hand Hygiene in Healthcare Settings; to correlate these attitudes with staff and hospital characteristics; and to examine the impact of staff attitudes toward the Hand Hygiene Guideline on self reported implementation of the Guideline. Methods A cross-sectional survey of staff in 70 ICUs in 39 U.S. hospitals, members of The National Nosocomial Infection Surveillance (NNIS) System. A survey, “Attitudes Regarding Practice Guidelines”, was administered anonymously to all willing staff during a site visit at each hospital; 1,359 ICU personnel: 1,003 nurses (74%), 228 physicians (17%), and 128 others (10%) responded. Results Significantly more positive attitudes toward practice guidelines were found among staff in pediatric as compared with adult ICUs (p<0.001). Nurses and other staff when compared with physicians had more positive attitudes toward guidelines in general but not toward the specific Hand Hygiene Guideline. Those with more positive attitudes were significantly more likely to report that they had implemented recommendations of the Guideline (p<0.001) and used an alcohol product for hand hygiene (p=0.002). Conclusions The majority of staff members were familiar with the CDC Hand Hygiene Guideline. Staff attitudes toward practice guidelines varied by type of ICU and by profession, and more positive attitudes were associated with significantly better self-reported guideline implementation. Because differences in staff attitudes might hinder or facilitate their acceptance and adoption of evidence-based practice guidelines, these results may have important implications for the education and/or socialization of ICU staff. PMID:17628198

Healthcare for migrants, participatory health research and implementation science--better health policy and practice through inclusion. The RESTORE project.

PubMed

MacFarlane, Anne; O'Reilly-de Brún, Mary; de Brún, Tomas; Dowrick, Christopher; O'Donnell, Catherine; Mair, Frances; Spiegel, Wolfgang; van den Muijsenbergh, Maria; van Weel Baumgarten, Evelyn; Lionis, Christos; Clissmann, Ciaran

2014-06-01

This is a time of unprecedented mobility across the globe. Healthcare systems need to adapt to ensure that primary care is culturally and linguistically appropriate for migrants. Evidence-based guidelines and training interventions for cultural competence and the use of professional interpreters are available across European healthcare settings. However, in real-world practice migrants and their healthcare providers 'get by' with a range of informal and inadequate strategies. RESTORE is an EU FP7 funded project, which is designed to address this translational gap. The objective of RESTORE is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultations in selected European primary care settings. RESTORE is a qualitative, participatory health project running from 2011-2015. It uses a novel combination of normalization process theory and participatory learning and action research to follow and shape the implementation journeys of relevant guidelines and training initiatives. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork, with a complementary health policy analysis led by Scotland. In each setting, key stakeholders, including migrants, are involved in participatory data generation and analysis. RESTORE will provide knowledge about the levers and barriers to the implementation of guidelines and training initiatives in European healthcare settings and about successful, transferrable strategies to overcome identified barriers. RESTORE will elucidate the role of policy in shaping these implementation journeys; generate recommendations for European policy driving the development of culturally and linguistically appropriate healthcare systems.

Evaluation of implementation of fasting guidelines for enterally fed critical care patients.

PubMed

Jenkins, Bethan; Calder, Philip C; Marino, Luise V

2018-02-15

Critically ill adults have increased nutrition risk. Prior to procedures patients are often fasted, leading to nutritional deficits. The use of fasting guidelines may therefore help reduce deficits from accumulating. The aim of this work was to determine the impact on nutrition support delivery following the implementation of fasting guidelines in addition to characterizing staff knowledge of the guidelines. Retrospective data were collected on n = 74 patients at two different time points; prior to launch of fasting guidelines and post launch, with regards to estimated nutritional requirements, nutritional targets, volume of enteral nutrition (EN) delivered and periods of fasting. Clinical variables of interest were collected for up to 14 days. Questionnaires assessing staff knowledge/barriers to usage of the fasting guidelines were administered to ICU staff. 3 ICUs (General, Cardiac and Neurosciences) within University Hospital Southampton NHS Foundation Trust. Mechanically ventilated adults in an ICU and receiving exclusive EN. Comparison was made between pre- and post-guideline implementation with statistically significant improvements in the % EN delivered (76.4 ± 11.8 vs. 84.1 ± 10.8 (p = 0.0009)) and duration of feeds withheld (41.5 ± 26.6 vs. 27.6 ± 20.8 h (p = 0.02)). There were non-significant improvements pre- and post-implementation in the % of energy and protein delivered (80.7 ± 16.4 vs. 86.5 ± 17.3 (p = 0.15 (NS)); 74 ± 18.3 vs. 79 ± 18.5 (p = 0.15 (NS))). 77% of staff were familiar with the guidelines, whilst 42% requested further education. The main barriers to guideline compliance were delays and unpredictable timing of procedures, and differing guidance from senior staff and non-ICU teams. Implementation of fasting guidelines led to significant improvements in EN delivery and reduced duration of feed breaks. The use of fasting guidelines is a positive step towards increasing nutrition delivery in the ICU. Further staff education and better planning around procedures is required to promote further adherence to the fasting guidelines. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Age Nutrition Chirugie (ANC) study: impact of a geriatric intervention on the screening and management of undernutrition in elderly patients operated on for colon cancer, a stepped wedge controlled trial.

PubMed

Dupuis, Marine; Kuczewski, Elisabetta; Villeneuve, Laurent; Bin-Dorel, Sylvie; Haine, Max; Falandry, Claire; Gilbert, Thomas; Passot, Guillaume; Glehen, Olivier; Bonnefoy, Marc

2017-01-07

Undernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines. The ANC ("Age Nutrition Chirurgie") study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study. The ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition. This study is registered in ClinicalTrials.gov NCT02084524 on March 11, 2014 (retrospectively registered).

Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services

DOT National Transportation Integrated Search

2018-01-11

Background: Performance measures are a key component of implementation, dissemination, and evaluation of evidence-based guidelines (EBGs). We developed performance measures for Emergency Medical Services (EMS) stakeholders to enable the implementatio...

A Study of the Implementation of Sex Education in Hong Kong Secondary Schools

ERIC Educational Resources Information Center

Che, Fok Shui

2005-01-01

Sex education is not treated as an important subject in the school curriculum of Hong Kong. The Hong Kong Education Department issued in 1986 and 1997, respectively, two guidelines on sex education for schools' reference. The 1997 Guidelines cover a broader conceptual framework relating to different aspects of human sexuality and also include…

Healthcare professionals' and policy makers' views on implementing a clinical practice guideline of hypertension management: a qualitative study.

PubMed

Lee, Ping Yein; Liew, Su May; Abdullah, Adina; Abdullah, Nurdiana; Ng, Chirk Jenn; Hanafi, Nik Sherina; Chia, Yook Chin; Lai, Pauline S M; Wong, Stalia S L; Khoo, Ee Ming

2015-01-01

Most studies have reported barriers to guideline usage mainly from doctors' perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals. This study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data. Two main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use. Barriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.

The implementation of European Association of Urology guidelines in the management of acute epididymo-orchitis.

PubMed

Garthwaite, Mary A E; Johnson, G; Lloyd, S; Eardley, I

2007-11-01

Acute epididymo-orchitis is a common and increasing problem. This retrospective study reviewed whether the European Association of Urology guidelines for the management of acute epididymo-orchitis, which form the basis of this Trust's present inter-departmental guidelines, are being effectively implemented. Case notes of 53 patients attending the emergency department with acute epididymo-orchitis over a 6-month period were reviewed retrospectively. The hospital results' database was used to confirm the diagnostic tests requested on patients at the time of their initial presentation. Of the study cohort, 26 patients were aged 35 years. The results demonstrated that a sexual history was documented in only 43.4% of cases. A mid-stream urine sample was sent for routine culture in 54.7% of cases whilst urine for the Chlamydia polymerase chain reaction (PCR) test was obtained in 17% and a urethral swab performed in 5.6%. Antibiotics were prescribed in 81% of cases. Of these patients, 46.5% received ciprofloxacin alone (mean age, 52 years; range, 18-87 years), 25.5% received doxycycline alone (mean age, 30 years; range, 18-45 years) and 21% received both ciprofloxacin and doxycycline (mean age, 33 years; range 18-49 years). In 26.4% of cases, verbal advice to attend a genito-urinary medicine clinic was given, whilst a formal telephone referral was made in only one case. Formal urological follow-up was arranged for only three out of 11 patients aged > 50 years. Although a joint emergency department/urology clinical protocol for the investigation and treatment of acute epididymo-orchitis already exists within the Trust, our current management conforms to this in only a minority of cases. Many different strategies can be employed in the implementation of clinical practice guidelines and all are associated with variable degrees of success. The regular movement of junior staff through each department necessitates that the distribution of management protocols and guidelines occurs at frequent intervals throughout the year and that their implementation is continuously monitored so that, if necessary, further implementation strategies can be employed.

Implementation of asthma guidelines to West Australian community pharmacies: an exploratory, quasi-experimental study

PubMed Central

Trevenen, Michelle; Murray, Kevin; Kendall, Peter A; Schneider, Carl R; Clifford, Rhonda

2016-01-01

Objectives Pharmacy assistants are often the first point of contact for patients presenting in community pharmacies. The current role of pharmacy assistants in the supply of asthma-reliever medications (short-acting β-agonists) was identified as a barrier to appropriate guideline-based care. The aim of this research was to devise and evaluate a team-based intervention to formalise the role of pharmacy assistants and to improve asthma guideline-based care in community pharmacy. Design A controlled pre-post intervention study was conducted in 336 metropolitan pharmacies located in Perth, Western Australia. Pharmacies were stratified into 2 groups (187 intervention and 149 control) based on known confounders for asthma control. The intervention was designed using a common-sense approach and resources developed included a checklist, videos and web page. Delivery was via workshops (25 pharmacies) or academic detailing (162 pharmacies). Pharmacy practice was assessed preintervention and postintervention via covert simulated patient methodology. Primary outcome measures included patient medical referral, device use demonstration and counselling, internal referral and/or direct involvement of a pharmacist in consultations. Results There was a significant increase in patient medical referral in intervention pharmacies from 32% to 47% (p=0.0007) from preintervention to postintervention, while control pharmacies showed a non-significant decrease from 50% to 44% (p=0.22). Device counselling was not routinely carried out at any stage or in any cohort of this research and no significant changes in internal referral were observed. Conclusions Increases in medical referral indicate that asthma guideline compliance can be improved in community pharmacy if implementation employs a team-based approach and involves pharmacy assistants. However, results were variable and the intervention did not improve practice related to device counselling or internal referral/pharmacist involvement. Undertaking more workshops may have improved results. Guideline implementation in community pharmacy should consider the role of pharmacy assistants and how to overcome logistical barriers to pharmacy participation in implementation activities. PMID:27580836

The role of nurses/social workers in using a multidimensional guideline for diagnosis of anxiety and challenging behaviour in people with intellectual disabilities.

PubMed

Pruijssers, Addy; van Meijel, Berno; Maaskant, Marian; Keeman, Noortje; Teerenstra, Steven; van Achterberg, Theo

2015-07-01

This study seeks (1) to investigate the impact of the implementation of the 'Diagnostic Guideline for Anxiety and challenging behaviours in clients with intellectual disability' on nurses/social workers' knowledge and self-efficacy; and (2) to evaluate the role of nurses/social workers in the diagnostic process when applying the guideline. Nurses/social workers have extensive contact with clients with intellectual disabilities. Despite this key position, the contribution of nurses/social workers to the diagnosis of mental health problems and challenging behaviours is rather limited. The authors developed the multidimensional 'Diagnostic Guideline for Anxiety and challenging behaviours'. In this article, the implementation of this guideline is evaluated concerning knowledge and self-efficacy of nurses/social workers, as well the role of nurses/social workers in the diagnostic process. This study employed a comparative multiple case study design. Qualitative and quantitative research methods. Working with the 'Diagnostic Guideline for Anxiety and challenging behaviours' led to a statistically significant increase in knowledge and self-efficacy among the nurses/social workers in the experimental condition, compared with nurses/social workers in the control condition. Nurses/social workers and psychologists appreciated the more active contribution of the nurses/social workers in the diagnostic process. Working with the guideline increased the knowledge and self-efficacy of nurses/social workers, and led to more active participation of nurses/social workers in the diagnostic process. After following a training programme, nurses/social workers can effectively contribute to the diagnostic process in clients with anxiety and related challenging behaviours. © 2015 John Wiley & Sons Ltd.

Code Team Training: Demonstrating Adherence to AHA Guidelines During Pediatric Code Blue Activations.

PubMed

Stewart, Claire; Shoemaker, Jamie; Keller-Smith, Rachel; Edmunds, Katherine; Davis, Andrew; Tegtmeyer, Ken

2017-10-16

Pediatric code blue activations are infrequent events with a high mortality rate despite the best effort of code teams. The best method for training these code teams is debatable; however, it is clear that training is needed to assure adherence to American Heart Association (AHA) Resuscitation Guidelines and to prevent the decay that invariably occurs after Pediatric Advanced Life Support training. The objectives of this project were to train a multidisciplinary, multidepartmental code team and to measure this team's adherence to AHA guidelines during code simulation. Multidisciplinary code team training sessions were held using high-fidelity, in situ simulation. Sessions were held several times per month. Each session was filmed and reviewed for adherence to 5 AHA guidelines: chest compression rate, ventilation rate, chest compression fraction, use of a backboard, and use of a team leader. After the first study period, modifications were made to the code team including implementation of just-in-time training and alteration of the compression team. Thirty-eight sessions were completed, with 31 eligible for video analysis. During the first study period, 1 session adhered to all AHA guidelines. During the second study period, after alteration of the code team and implementation of just-in-time training, no sessions adhered to all AHA guidelines; however, there was an improvement in percentage of sessions adhering to ventilation rate and chest compression rate and an improvement in median ventilation rate. We present a method for training a large code team drawn from multiple hospital departments and a method of assessing code team performance. Despite subjective improvement in code team positioning, communication, and role completion and some improvement in ventilation rate and chest compression rate, we failed to consistently demonstrate improvement in adherence to all guidelines.

A cross-sectional survey of policies guiding second stage labor in urban Japanese hospitals, clinics and midwifery birth centers.

PubMed

Baba, Kaori; Kataoka, Yaeko; Nakayama, Kaori; Yaju, Yukari; Horiuchi, Shigeko; Eto, Hiromi

2016-02-24

The Japan Academy of Midwifery developed and disseminated the '2012 Evidence-based Guidelines for Midwifery Care (Guidelines for Midwives)' for low-risk births to achieve a more uniform standard of care during childbirth in Japan. The objective of this study was to cross-sectional survey policy implementation regarding care during the second stage of labor at Japanese hospitals, clinics, and midwifery birth centers, and to compare those policies with the recommendations in Guidelines for Midwives. This study was conducted in the four major urbanized areas (e.g. Tokyo) of the Kanto region of Japan. Respondents were chiefs of the institutions (obstetricians/midwives), nurse administrators (including midwives) of the obstetrical departments, or other nurse/midwives who were well versed in the routine care of the targeted institutions. The Guidelines implementation questionnaire comprised 12 items. Data was collected from October 2010 to July 2011. The overall response was 255 of the 684 institutions (37%). Of the total responses 46% were hospitals, 26% were clinics and 28% were midwifery birth centers. Few institutions reported perineal massage education for 'almost all cases'. Using 'active birth' were all midwifery birth centers, 56% hospitals and 32% clinics. Few institutions used water births. The majority of hospitals (73%) and clinics (80%) but a minority (39%) of midwifery birth centers reported 'not implemented' about applying warm compress to the perineum. Few midwifery birth centers (10%) and more hospitals (38%) and clinics (50%) had a policy for valsalva as routine care. Many hospitals (90%) and clinics (88%) and fewer midwifery birth centers (54%) offered hands-on technique to provide perineal support during birth. A majority of institutions used antiseptic solution for perineal disinfection. Few institutions routinely used episiotomies for multiparas, however routine use for primiparas was slightly more in hospitals (21%) and clinics (25%). All respondents used fundal pressure as consistent with guidelines. Not many institutions implemented the hands and knees position for correcting fetal abnormal rotation. This survey has provided new information about the policies instituted in three types of institutions guiding second stage labor in four metropolitan areas of Japan. There existed considerable differences among institutions' practice. There were also many gaps between reported policies and evidence-based Guidelines for Midwives, therefore new strategies are needed in Japan to realign institution's care policies with evidenced based guidelines.

From guideline modeling to guideline execution: defining guideline-based decision-support services.

PubMed Central

Tu, S. W.; Musen, M. A.

2000-01-01

We describe our task-based approach to defining the guideline-based decision-support services that the EON system provides. We categorize uses of guidelines in patient-specific decision support into a set of generic tasks--making of decisions, specification of work to be performed, interpretation of data, setting of goals, and issuance of alert and reminders--that can be solved using various techniques. Our model includes constructs required for representing the knowledge used by these techniques. These constructs form a toolkit from which developers can select modeling solutions for guideline task. Based on the tasks and the guideline model, we define a guideline-execution architecture and a model of interactions between a decision-support server and clients that invoke services provided by the server. These services use generic interfaces derived from guideline tasks and their associated modeling constructs. We describe two implementations of these decision-support services and discuss how this work can be generalized. We argue that a well-defined specification of guideline-based decision-support services will facilitate sharing of tools that implement computable clinical guidelines. PMID:11080007

Controlling droplet-transmitted respiratory infections

PubMed Central

Hogg, William; Huston, Patricia

2006-01-01

OBJECTIVE To promote incorporation of new guidelines on control of respiratory infections into family physicians’ practices. SOURCES OF INFORMATION The World Health Organization website on pandemic influenza, the Canadian Pandemic Influenza Plan, the Ontario guidelines on respiratory infection control, and research on implementing guidelines into family practice were reviewed. We also researched and calculated what the costs of implementing the guidelines would be. MAIN MESSAGE Effective control of respiratory infections in physicians’ offices can be achieved by displaying signs in the waiting room, having reception staff give masks to patients with cough and fever, instructing these patients to clean their hands with alcohol gel and to sit at least 1 m from others, inquiring about patients’ or their close contacts’ recent travel, using disinfectant wipes to clean possibly contaminated surfaces in waiting rooms and examining areas, and having staff and care providers wear masks and wash hands or use alcohol gel. The approximate annual cost of incorporating the guidelines is about $800 per physician. CONCLUSION Because the outbreak of an influenza pandemic is likely imminent, implementing standard guidelines for control of respiratory infections in primary care offices seems wise. Following these guidelines would help prevent patients and staff from contracting serious respiratory illnesses. PMID:17279182

Healthier vending machines in workplaces: both possible and effective.

PubMed

Gorton, Delvina; Carter, Julie; Cvjetan, Branko; Ni Mhurchu, Cliona

2010-03-19

To develop healthier vending guidelines and assess their effect on the nutrient content and sales of snack products sold through hospital vending machines, and on staff satisfaction. Nutrition guidelines for healthier vending machine products were developed and implemented in 14 snack vending machines at two hospital sites in Auckland, New Zealand. The guidelines comprised threshold criteria for energy, saturated fat, sugar, and sodium content of vended foods. Sales data were collected prior to introduction of the guidelines (March-May 2007), and again post-introduction (March-May 2008). A food composition database was used to assess impact of the intervention on nutrient content of purchases. A staff survey was also conducted pre- and post-intervention to assess acceptability. Pre-intervention, 16% of staff used vending machines once a week or more, with little change post-intervention (15%). The guidelines resulted in a substantial reduction in the amount of energy (-24%), total fat (-32%), saturated fat (-41%), and total sugars (-30%) per 100 g product sold. Sales volumes were not affected, and the proportion of staff satisfied with vending machine products increased. Implementation of nutrition guidelines in hospital vending machines led to substantial improvements in nutrient content of vending products sold. Wider implementation of these guidelines is recommended.

Moving Past Exploration and Adoption: Considering Priorities for Implementing Mobile Learning by Nurses.

PubMed

Mather, Carey; Cummings, Elizabeth

2017-01-01

Successful implementation of mobile technology for informal learning and continuing professional development within healthcare settings cannot be achieved or sustained, until end-users recognise that the benefits of using this innovation, outweigh the issues of non-use. At a systems level there is a need for standards, guidelines and codes of conduct to support deployment of mobile technology at an individual level. The aim of this research was to explore findings of a previous focus group study to elucidate priorities for action, provide evidence and focus impetus for advocating progression of the installation of standards and guidelines at an organisation level. The study confirms nurse supervisors' preparedness and readiness to employ mobile learning at point of care. However, successful implementation requires organisations engaging with, and embracing the evolving digital landscape, and supporting this new andragogy. Organisational level commitment will promote contemporary nursing practice, support the best clinical outcomes for patients, and provide educational support for nurses. Nurse leaders and professional bodies must drive and guide development of robust standards, guidelines, and codes of conduct to prioritise mobile learning as a component of digital professionalism within healthcare organisations.

A survey of the awareness, knowledge, policies and views of veterinary journal Editors-in-Chief on reporting guidelines for publication of research

PubMed Central

2014-01-01

Background Wider adoption of reporting guidelines by veterinary journals could improve the quality of published veterinary research. The aims of this study were to assess the knowledge and views of veterinary Editors-in-Chief on reporting guidelines, identify the policies of their journals, and determine their information needs. Editors-in-Chief of 185 journals on the contact list for the International Association of Veterinary Editors (IAVE) were surveyed in April 2012 using an online questionnaire which contained both closed and open questions. Results The response rate was 36.8% (68/185). Thirty-six of 68 editors (52.9%) stated they knew what a reporting guideline was before receiving the questionnaire. Editors said they had found out about reporting guidelines primarily through articles in other journals, via the Internet and through their own journal. Twenty of 57 respondents (35.1%) said their journal referred to reporting guidelines in its instructions to authors. CONSORT, REFLECT, and ARRIVE were the most frequently cited. Forty-four of 68 respondents (68.2%) believed that reporting guidelines should be adopted by all refereed veterinary journals. Qualitative analysis of the open questions revealed that lack of knowledge, fear, resistance to change, and difficulty in implementation were perceived as barriers to the adoption of reporting guidelines by journals. Editors suggested that reporting guidelines be promoted through communication and education of the veterinary community, with roles for the IAVE and universities. Many respondents believed a consensus policy on guideline implementation was needed for veterinary journals. Conclusions Further communication and education about reporting guidelines for editors, authors and reviewers has the potential to increase their adoption by veterinary journals in the future. PMID:24410882

Designing, Developing, and Implementing Diversity Training: Guidelines for Practitioners.

ERIC Educational Resources Information Center

Kincaid, Tanna M.; Horner, Erin R.

1997-01-01

Discusses diversity in the workplace and offers guidelines for practitioners in designing, developing, and implementing diversity training. Highlights include linking the diversity initiative to the organization's mission, cultural climate assessments, reviewing policies and procedures, needs assessment, learner analysis, establishing objectives,…

Mandatory implementation of NICE Guidelines for the care of bipolar disorder and other conditions in England and Wales.

PubMed

Morriss, Richard

2015-09-30

Bipolar disorder is a common long-term mental health condition characterised by episodes of mania or hypomania and depression resulting in disability, early death, and high health and society costs. Public money funds the National Institute of Healthcare and Clinical Excellence (NICE) to produce clinical guidelines by systematically identifying the most up to date research evidence and costing its main recommendations for healthcare organisations and professionals to follow in England and Wales. Most governments, including those of England and Wales, need to improve healthcare but at reduced cost. There is evidence, particularly in bipolar disorder, that systematically following clinical guidelines achieves these outcomes. NICE clinical guidelines, including those regarding bipolar disorder, remain variably implemented. They give clinicians and patients a non-prescriptive basis for deciding their care. Despite the passing of the Health and Social Care Act in 2012 in England requiring all healthcare organisations to consider NICE clinical guidelines in commissioning, delivering, and inspecting healthcare services, healthcare organisations in the National Health Service may ignore them with little accountability and few consequences. There is no mechanism to ensure that healthcare professionals know or consider them. Barriers to their implementation include the lack of political and professional leadership, the complexity of the organisation of care and policy, mistrust of some processes and recommendations of clinical guidelines, and a lack of a clear implementation model, strategy, responsibility, or accountability. Mitigation to these barriers is presented herein. The variability, safety, and quality of healthcare might be improved and its cost reduced if the implementation of NICE clinical guidelines, such as those for bipolar disorder, were made the minimum starting point for clinical decision-making and mandatory responsibilities of all healthcare organisations and professionals.

Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort.

PubMed

Morbach, Caroline; Wagner, Martin; Güntner, Stefan; Malsch, Carolin; Oezkur, Mehmet; Wood, David; Kotseva, Kornelia; Leyh, Rainer; Ertl, Georg; Karmann, Wolfgang; Heuschmann, Peter U; Störk, Stefan

2017-05-05

Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation. Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered. 509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription. In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists. This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial.

PubMed

Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming; Maindal, Helle Terkildsen; Petersen, Karin Dam; Bendtsen, Mette Dahl; Jensen, Martin Bach

2016-10-21

Guidelines are often slowly adapted into clinical practice. However, actively supporting healthcare professionals in evidence-based treatment may speed up guideline implementation. Danish low back pain (LBP) guidelines focus on primary care treatment of LBP, to reduce referrals from primary care to secondary care. The primary aim of this project was to reduce secondary care referral within 12 weeks by a multifaceted implementation strategy (MuIS). In a cluster randomised design, 189 general practices from the North Denmark Region were invited to participate. Practices were randomised (1:1) and stratified by practice size to MuIS (28 practices) or a passive implementation strategy (PaIS; 32 practices). Included were patients with LBP aged 18 to 65 years who were able to complete questionnaires, had no serious underlying pathology, and were not pregnant. We developed a MuIS including outreach visits, quality reports, and the STarT Back Tool for subgrouping patients with LBP. Both groups were offered the usual dissemination of guidelines, guideline-concordant structuring of the medical record, and a new referral opportunity for patients with psycho-social problems. In an intention-to-treat analysis, the primary and secondary outcomes pertained to the patient, and a cost-effectiveness analysis was performed from a healthcare sector perspective. Patients and the assessment of outcomes were blinded. Practices and caregivers delivering the interventions were not blinded. Between January 2013 and July 2014, 60 practices were included, of which 54 practices (28 MuIS, 26 PaIS) included 1101 patients (539 MuIS, 562 PaIS). Follow-up data for the primary outcome were available on 100 % of these patients. Twenty-seven patients (5.0 %) in the MuIS group were referred to secondary care vs. 59 patients (10.5 %) in the PaIS group. The adjusted odds ratio (AOR) was 0.52 [95 % CI 0.30 to 0.90; p = 0.020]. The MuIS was cost-saving £-93.20 (£406.51 vs. £499.71 per patient) after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]). Using a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines. ClinicalTrials.gov, NCT01699256.

Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines.

PubMed

Ahlqvist, Margary; Bogren, Agneta; Hagman, Sari; Nazar, Isabel; Nilsson, Katarina; Nordin, Karin; Valfridsson, Berit Sunde; Söderlund, Mona; Nordström, Gun

2006-11-01

This study aimed at evaluating the outcome of implemented evidence-based clinical guidelines by means of surveying the frequency of thrombophlebitis, nurses' care, handling and documentation of peripheral intravenous cannulae. Peripheral intravenous cannulae are frequently used for vascular access and, thereby, the patients will be exposed to local and systemic infectious complications. Evidence-based knowledge of how to prevent these complications and how to care for patients with peripheral intravenous cannula is therefore of great importance. Deficient care, handling and documentation of peripheral intravenous cannulae have previously been reported. A cross-sectional survey was conducted by a group of nurses at three wards at a university hospital before and after the implementation of the evidence-based guidelines. A structured observation protocol was used to review the frequency of thrombophlebitis, the nurses' care, handling and the documentation of peripheral intravenous cannulae in the patient's record. A total of 107 and 99 cannulae respectively were observed before and after the implementation of the guidelines. The frequency of peripheral intravenous cannulae without signs of thrombophlebitis increased by 21% (P < 0.01) and the use of cannula size 0.8 mm increased by 22% (P < 0.001). Nurses' documentation of peripheral intravenous cannula improved significantly (P < 0.001). We conclude that implementation of the guidelines resulted in significant improvements by means of decreased frequency of signs of thrombophlebitis, increased application of smaller cannula size (0.8 mm), as well as of the nurses' documentation in the patient's record. Further efforts to ameliorate care and handling of peripheral intravenous cannulae are needed. This can be done by means of increasing nurses' knowledge and recurrent quality reviews. Well-informed patients can also be more involved in the care than is common today.

Impact of the implementation of an evidence-based guideline on diagnostic testing, management, and clinical outcomes for infants with bronchiolitis

PubMed Central

Henao-Villada, Ricardo; Sossa-Briceño, Monica P.; Rodríguez-Martínez, Carlos E.

2016-01-01

Background: Although bronchiolitis poses a significant health problem in low- and middle-income countries (LMICs), to the best of our knowledge, to date it has not been determined whether evidence-based bronchiolitis clinical practice guidelines (CPGs) complemented by standardized educational strategies reduce the use of unnecessary diagnostic tests and medications and improve clinically important outcomes in LMICs. Methods: In an uncontrolled before and after study, we assessed the impact of the implementation of an evidence-based bronchiolitis CPG on physician behavior and the care of infants with bronchiolitis by comparing pre-guideline (March to August 2014) and post-guideline (March to August 2015) use of diagnostic tests and medications through an electronic medical record review in a children’s hospital in Bogota, Colombia. We also sought to assess the impact of the implementation of the CPG on clinically important outcomes such as lengths of stay, hospital admissions, intensive care admissions, and hospital readmissions. Results: Data from 662 cases of bronchiolitis (pre-guideline period) were compared with the data from 703 cases (post-guideline period). On comparing the pre- and post-guideline periods, it was seen that there was a significant increase in the proportion of patients with an appropriate diagnosis and treatment of bronchiolitis (36.4% versus 44.5%, p = 0.003), and there were statistically significant decreases in the use of a hemogram (33.2% versus 26.6%, p=0.010), procalcitonin (3.9% versus 1.6%, p=0.018), nebulized beta-2 agonists (45.6% versus 3.4%, p < 0.001), nebulized anticholinergics (3.3% versus 1.4%, p= 0.029), and nebulized epinephrine (16.2% versus 7.8%, p < 0.001). Likewise, a significant increase in the use of nebulized hypertonic saline was seen (79.6% versus 91.7%, p < 0.001). However, implementation of the CPG for bronchiolitis was not associated with significant changes in clinically important outcomes. Conclusions: The development and implementation of a good quality bronchiolitis CPG is associated with a significant increase in the proportion of cases with an appropriate diagnosis and treatment of the disease in the context of a university-based hospital located in the capital of an LMIC. However, we could not demonstrate an improvement in clinically important outcomes such as any of the bronchiolitis severity parameters. PMID:27492738

Concussion guideline implementation perceptions and experiences among parents of community-level Australian Football junior players

PubMed Central

White, Peta E; Register-Mihalik, Johna; Donaldson, Alex; Sullivan, S John

2017-01-01

Background/aim Concussion guidelines exist for multiple community sports. Parents are key stakeholders in guideline implementation and in appropriate responses following concussive injury. The purpose of this qualitative investigation was to understand how parents of community-level Australian Football (AF) players experience and perceive concussion guidelines in order to inform the design and implementation of concussion guidelines in community sport. Methods A cross-sectional qualitative approach was adopted to allow for an open and detailed exploration of the views of parents of junior community AF players (ie, those aged <16 years) regarding concussion guidelines of the AF League (AFL)—the national governing body for AF. Participants were 15 parents of junior community AF players from two clubs affiliated with a large regional community AF League. Results The key experiences and perceptions of the parents included appreciation that the guidelines outlined the postconcussion process that should be followed, desires for better understanding of the guidelines by general practitioners (ie, medical doctors) who care for children with concussion, having more readily available information for parents and receiving more formal policy guiding timing of return-to-participation following concussion. Difficulties with the guidelines not addressing delayed presentations of concussion were also frequently mentioned. Conclusions Parents are key stakeholders in concussion prevention and care in community sport. As such, their input should be considered when developing guidelines and resources for community sport. Furthermore, concussion information should be made available to parents in an easily accessible and community-friendly form. PMID:28761707

Understanding barriers to implementing the Norwegian national guidelines for healthy school meals: a case study involving three secondary schools.

PubMed

Holthe, Asle; Larsen, Torill; Samdal, Oddrun

2011-07-01

The main goal of the present study was to investigate the barriers to implementing the Norwegian national guidelines for healthy school meals as perceived by principals, project leaders, teachers and students. This study employed a multiple-case design using an explorative approach. Data were collected at three secondary schools in Norway participating in the intervention project Physical activity and healthy school meals. Individual interviews were conducted with school principals and project leaders, and focus group interviews were conducted separately with teachers and students. Four categories of barriers were identified: (1) lack of adaptation of the guidelines to the target group; (2) lack of resources and funding; (3) conflicting values and goals; and (4) access to unhealthy food outside school. The research identified differences in perceived barriers between the staff responsible for implementation and the students as the target group of the measures. All staff groups perceived barriers relating to both resources, and conflicting values and goals. The teachers were more concerned about issues of relevance for adaptation to the target groups than were the principals and project leaders. The students were concerned mostly with issues directly affecting their experience with items offered in the canteen. © 2010 Blackwell Publishing Ltd.

An extended field test of the WHO severe malnutrition guidelines in hospitals in developing countries: preliminary observations.

PubMed

Deen, J L; Weber, M; Qazi, S; Fontaine, O

2003-01-01

The WHO has published guidelines for the inpatient management of severe malnutrition. A qualitative study in hospitals in developing countries is being conducted to document the re-organisation of the clinical ward and support services required to implement these guidelines and to gain an impression of the feasibility and sustainability of such a re-organisation. Following a postal survey of experts in the management of malnutrition in children in developing countries, hospitals were contacted and asked if they were interested to participate in the study. If so, they were requested to submit background information about admission patterns, the frequency of malnutrition, and current practice. Based on this information, hospitals are selected for a preliminary visit. Following this, and the final selection, a paediatrician conducts three visits to the study hospital over a one-year period to appraise the current practice, assist the health staff in recognising the strengths and shortcomings of their current management, help them find locally appropriate solutions, support the implementation process through a participatory approach and assess the outcome. A structured survey instrument is used to guide the assessment and identification of problems. Results of the first visit, which documents the existing situation, and changes identified by staff and implemented during the second visit are presented.

Investigating the use of NICE guidelines and IAPT services in the treatment of depression

PubMed Central

2012-01-01

Background There is evidence that the National Institute for Health and Clinical Excellence (NICE) guidelines for mental health disorders are used to varying degrees in primary care. A lack of access to cognitive–behavioural therapy (CBT) has been found to be a barrier to their implementation. The Improving Access to Psychological Therapies (IAPT) initiative was created in 2007 to increase the availability of NICE-recommended psychological treatments for depression and anxiety disorders within the National Health Service in England. Aim This study aims to investigate whether general practitioners (GPs) who have access to IAPT services and use NICE guidelines are more likely to use NICE concordant treatments for depression than those who do not. Depression was chosen as it is the most common mental health problem facing primary care physicians. Method Questionnaires were sent to 830 GPs in southeast England and six GPs were interviewed. The response rate to the questionnaires was 27% (n = 222). Results Ninety-five per cent of GPs were aware of the NICE guidelines for depression, and 76% had read them. Concordance with the guidelines was significantly higher when GPs had access to a local IAPT service or had read the NICE guidelines. Conclusions The interviews revealed favourable views to IAPT services when used, although access to treatments was still a common barrier to the implementation of the NICE guidelines for depression. PMID:23997821

Formulary management of recombinant factor VIIa at an academic medical center.

PubMed

Owen, Phillip S; Golightly, Larry K; MacLaren, Robert; Ferretti, Kenneth A; Badesch, David B

2008-06-01

Recombinant human coagulation factor VIIa (rVIIa) is a procoagulant indicated for treatment of bleeding in patients with hemophilia. A large proportion of rVIIa utilization is for off-label administration in nonhemophiliac patients with acute hemorrhage. Concerns of potentially inappropriate use, safety, and cost of rVIIa led to efforts to standardize use of this agent. To comparatively describe the utilization of rVIIa upon implementation of an evidence-based guideline at a university hospital. With advisory direction from a multidisciplinary task force, an evidence-based guideline for use of rVIIa was developed, approved, and fully implemented. Assessment of appropriateness of use and retrospective review were required for all cases. Effects of these actions were evaluated by auditing and comparing rVIIa use in patients treated in two 6-month observation periods before and after guideline implementation. Outcomes assessed were proportions of patients deemed appropriate to receive rVIIa, compliance with dosing recommendations, and acquisition costs. Twenty-two and 29 patients were treated in the periods before and after guideline implementation, respectively. Patient characteristics were similar, except more cardiothoracic surgeries were performed in patients treated before implementation of the guideline. Indications for rVIIa use were judged appropriate in 21 (95.5%) before-cases and in all (100%) after-cases. The dose was compliant in 1 (4.6%) before-case and 27 (93.1%) after-cases (p < 0.001). Mean dosages of rVIIa administered were 81.8 microg/kg and 45.3 microg/kg in before- and after-cases, respectively (p < 0.001). During the respective periods of observation, amounts of rVIIa purchased monthly averaged 42.6 mg and 21.8 mg, a 49% difference. Semiannual expenditures for rVIIa decreased approximately $110,000 following guideline implementation. Patient outcomes were similar. A guideline based on currently available evidence can serve to sustain the clinical appropriateness of rVIIa therapy and substantially decrease costs.

Modeling the value for money of changing clinical practice change: a stochastic application in diabetes care.

PubMed

Hoomans, Ties; Abrams, Keith R; Ament, Andre J H A; Evers, Silvia M A A; Severens, Johan L

2009-10-01

Decision making about resource allocation for guideline implementation to change clinical practice is inevitably undertaken in a context of uncertainty surrounding the cost-effectiveness of both clinical guidelines and implementation strategies. Adopting a total net benefit approach, a model was recently developed to overcome problems with the use of combined ratio statistics when analyzing decision uncertainty. To demonstrate the stochastic application of the model for informing decision making about the adoption of an audit and feedback strategy for implementing a guideline recommending intensive blood glucose control in type 2 diabetes in primary care in the Netherlands. An integrated Bayesian approach to decision modeling and evidence synthesis is adopted, using Markov Chain Monte Carlo simulation in WinBUGs. Data on model parameters is gathered from various sources, with effectiveness of implementation being estimated using pooled, random-effects meta-analysis. Decision uncertainty is illustrated using cost-effectiveness acceptability curves and frontier. Decisions about whether to adopt intensified glycemic control and whether to adopt audit and feedback alter for the maximum values that decision makers are willing to pay for health gain. Through simultaneously incorporating uncertain economic evidence on both guidance and implementation strategy, the cost-effectiveness acceptability curves and cost-effectiveness acceptability frontier show an increase in decision uncertainty concerning guideline implementation. The stochastic application in diabetes care demonstrates that the model provides a simple and useful tool for quantifying and exploring the (combined) uncertainty associated with decision making about adopting guidelines and implementation strategies and, therefore, for informing decisions about efficient resource allocation to change clinical practice.

Results of an Integrative Analysis: A Call for Contextualizing HIV and AIDS Clinical Practice Guidelines to Support Evidence-Based Practice.

PubMed

Edwards, Nancy; Kahwa, Eulalia; Hoogeveen, Katie

2017-12-01

Practice guidelines aim to improve the standard of care for people living with HIV/AIDS. Successfully implementing guidelines requires tailoring them to populations served and to social and organizational influences on care. To examine dimensions of context, which nurses and midwives described as having a significant impact on their care of patients living with HIV/AIDS in Kenya, Uganda, South Africa, and Jamaica and to determine whether HIV/AIDS guidelines include adaptations congruent with these dimensions of context. Two sets of data were used. The first came from a qualitative study. In-depth interviews were conducted with purposively selected nurses, midwives, and nurse managers from 21 districts in four study countries. A coding framework was iteratively developed and themes inductively identified. Context dimensions were derived from these themes. A second data set of published guidelines for HIV/AIDS care was then assembled. Guidelines were identified through Google and PubMed searches. Using a deductive integrative analysis approach, text related to context dimensions was extracted from guidelines and categorized into problem and strategy statements. Ninety-six individuals participated in qualitative interviews. Four discrete dimensions of context were identified: health workforce adequacy, workplace exposure risk, workplace consequences for nurses living with HIV/AIDS, and the intersection of work and family life. Guidelines most often acknowledged health human resource constraints and presented mitigation strategies to offset them, and least often discussed workplace consequences and the intersections of family and work life. Guidelines should more consistently acknowledge diverse implementation contexts, propose how recommendations can be adapted to these realities, and suggest what role frontline healthcare providers have in realizing the structural changes necessary for healthier work environments and better patient care. Guideline recommendations should include more explicit advice on adapting their recommendations to different care conditions. © 2017 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.

Cancer-related fatigue: appraising evidence-based guidelines for screening, assessment and management.

PubMed

Pearson, Elizabeth J M; Morris, Meg E; McKinstry, Carol E

2016-09-01

There is inconsistent management of cancer-related fatigue (CRF) by health professionals worldwide. This research aims to identify the most appropriate guidelines for the management of cancer-related fatigue. A systematic search of international literature identified evidence-based clinical practice guidelines for CRF. Four reviewers independently appraised the highest quality guidelines using the AGREE-II instrument and National Heath and Medical Research Council (NHMRC) guideline standards. Five guidelines met the inclusion criteria. Of these, the 2015 Canadian Association of Psychosocial Oncology (CAPO) CRF guidelines and the 2014 American Society of Clinical Oncology (ASCO) fatigue guidelines for cancer survivors were selected for in-depth appraisal. The CAPO guideline scored higher than the ASCO for five domains of the AGREE-II. For one domain, the differences were statistically significant (p ≤ 0.05). The CAPO guideline met 37 of 47 NHMRC mandatory guideline standards and the ASCO guideline met 20. The difference in the proportion of standards met was statistically significant for one domain (p ≤ 0.05). Both guidelines had low scores for applicability and implementation. Currently, the CAPO guideline for cancer-related fatigue has the strongest evidence for use. To enhance implementation, further strategies for guideline dissemination and application are needed.

Increased risk of RSV infection in children with Down's syndrome: clinical implementation of prophylaxis in the European Union.

PubMed

van Beek, Dianne; Paes, Bosco; Bont, Louis

2013-01-01

Prospective cohort studies show that Down's syndrome (DS) is an independent risk factor for hospitalization for RSV bronchiolitis. It is unknown whether this observation has been translated into specific management for DS children. The primary goal was to assess the knowledge of healthcare providers in the European Union about RSV infection in DS children and to determine whether it influenced the implementation of prophylaxis. DS caregivers were surveyed using a standardized questionnaire, and country-specific guidelines were obtained. Fifty-three caregivers participated. Thirty-nine (86.7%) had knowledge of the increased risk of severe RSV infection in DS children, and 30 (71.4%) graded that it was important to have a statement on the use of RSV prophylaxis in existing guidelines. Twenty-eight participants had a local DS guideline; hard copies of twelve unique guidelines were obtained. Only one (8.3%) contained a statement on RSV prophylaxis for DS, and five considered such a statement for the next version. Conclusion. Most pediatricians had knowledge that DS children have an increased risk of severe RSV infection. Despite the lack of a specific RSV prophylaxis trial in DS, they felt that a statement on RSV prophylaxis in DS guidelines was important, but this was rarely present in current guidelines.

Increased Risk of RSV Infection in Children with Down's Syndrome: Clinical Implementation of Prophylaxis in the European Union

PubMed Central

Paes, Bosco; Bont, Louis

2013-01-01

Prospective cohort studies show that Down's syndrome (DS) is an independent risk factor for hospitalization for RSV bronchiolitis. It is unknown whether this observation has been translated into specific management for DS children. The primary goal was to assess the knowledge of healthcare providers in the European Union about RSV infection in DS children and to determine whether it influenced the implementation of prophylaxis. DS caregivers were surveyed using a standardized questionnaire, and country-specific guidelines were obtained. Fifty-three caregivers participated. Thirty-nine (86.7%) had knowledge of the increased risk of severe RSV infection in DS children, and 30 (71.4%) graded that it was important to have a statement on the use of RSV prophylaxis in existing guidelines. Twenty-eight participants had a local DS guideline; hard copies of twelve unique guidelines were obtained. Only one (8.3%) contained a statement on RSV prophylaxis for DS, and five considered such a statement for the next version. Conclusion. Most pediatricians had knowledge that DS children have an increased risk of severe RSV infection. Despite the lack of a specific RSV prophylaxis trial in DS, they felt that a statement on RSV prophylaxis in DS guidelines was important, but this was rarely present in current guidelines. PMID:23878586

Disability Policy Implementation From a Cross-Cultural Perspective.

PubMed

Verdugo, Miguel A; Jenaro, Cristina; Calvo, Isabel; Navas, Patricia

2017-07-01

Implementation of disability policy is influenced by social, political, and cultural factors. Based on published work, this article discusses four guidelines considered critical for successful policy implementation from a cross-cultural perspective. These guidelines are to: (a) base policy implementation on a contextual analysis, (b) employ a value-based approach, (c) align the service delivery system both vertically and horizontally, and (d) engage in a partnership in policy implementation. Public policy should be understood from a systems perspective that includes cross-cultural issues, such as how different stakeholders are acting and the way they plan and implement policy.

A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study.

PubMed

Fleiszer, Andrea R; Semenic, Sonia E; Ritchie, Judith A; Richer, Marie-Claire; Denis, Jean-Louis

2016-01-01

Best practice guidelines are a tool for narrowing research-to-practice gaps and improving care outcomes. There is some empirical understanding of guideline implementation in nursing settings, yet there has been almost no consideration of the longer-term sustainability of guideline-based practice improvements. Many healthcare innovations are not sustained, underscoring the need for knowledge about how to promote their survival. To understand how a nursing best practice guidelines program was sustained on acute healthcare center nursing units. We undertook a qualitative descriptive case study of an organization-wide nursing best practice guidelines program with four embedded nursing unit subcases. The setting was a large, tertiary/quaternary urban health center in Canada. The nursing department initiated a program to enhance patient safety through the implementation of three guidelines: falls prevention, pressure ulcer prevention, and pain management. We selected four inpatient unit subcases that had differing levels of program sustainability at an average of almost seven years post initial program implementation. Data sources included 39 key informant interviews with nursing leaders/administrators and frontline nurses; site visits; and program-related documents. Data collection and content analysis were guided by a framework for the sustainability of healthcare innovations. Program sustainability was characterized by three elements: benefits, routinization, and development. Seven key factors most accounted for the differences in the level of program sustainability between subcases. These factors were: perceptions of advantages, collaboration, accountability, staffing, linked levels of leadership, attributes of formal unit leadership, and leaders' use of sustainability activities. Some prominent relationships between characteristics and factors explained long-term program sustainability. Of primary importance was the extent to which unit leaders used sustainability-oriented activities in both regular and responsive ways to attend to the relationships between sustainability characteristics and factors. Continued efforts are required to ensure long-term program sustainability on nursing units. Persistent and adaptive orchestration of sustainability-oriented activities by formal unit leadership teams is necessary for maintaining best practice guidelines over the long term. Leaders should consider a broad conceptualization of sustainability, beyond guideline-based benefits and routinization, because the development of unit capacity in response to changing circumstances appears essential. Copyright © 2015 Elsevier Ltd. All rights reserved.

Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008.

PubMed

Butalid, Ligaya; Bensing, Jozien M; Verhaak, Peter F M

2014-03-01

To examine whether GPs' communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s. From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as 'completely psychosocial' were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time. We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9-3.2 to 1.4-1.6 between periods). Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy. GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients' personal contexts and giving room to their emotions. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

77 FR 37248 - Delegations of Authority for the Office of Housing-Federal Housing Administration (FHA...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-20

... office develops and implements policies and guidelines for the loan origination, construction, asset.... It develops and implements policies and guidelines for plans and specifications, construction contracts, construction monitoring, construction draws, and closeout of the facility construction. This...

75 FR 61504 - Global Implementation of the Veterinary Medicinal Products Guidelines

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-05

... countries to allocate appropriate human and financial resources to veterinary services and laboratories to... DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA-2010-N-0497] Global Implementation of the Veterinary Medicinal Products Guidelines AGENCY: Food and Drug...

Implementation of institutional antiemetic guidelines for low emetic risk chemotherapy with docetaxel: a clinical and cost evaluation.

PubMed

Hayashi, Toshinobu; Ikesue, Hiroaki; Esaki, Taito; Fukazawa, Mami; Abe, Motoaki; Ohno, Shinji; Tomizawa, Tatsuru; Oishi, Ryozo

2012-08-01

The purposes of this study were to evaluate the effect of implementation of institutional guidelines for low emetic risk chemotherapy with docetaxel and estimate the cost saving for all low emetic risk chemotherapies. We examined the clinical effect of preparing and implementing institutional antiemetic guidelines for the breast cancer patients receiving adjuvant docetaxel therapy. Although the antiemetic medication for such patients used to be ondansetron 4 mg plus dexamethasone 8 mg (OND + DEX), it was changed to dexamethasone (DEX) 12 mg alone after implementation of the institutional guidelines. The effectiveness and adverse effects of DEX alone (56 patients, 205 courses) were compared with those of OND + DEX (41 patients, 151 courses). The cost saving was calculated from the antiemetic costs in both groups. The annual cost saving was estimated from the number of all low emetic risk chemotherapies in a year. The incidences of nausea (19.5% versus 16.1%), vomiting (2.4% versus 0%), constipation (34.1% versus 30.4%), and insomnia (17.1% versus 17.9%) were not significantly different between the OND + DEX group and DEX alone group. In all low emetic risk chemotherapies, US $78,883 of potential cost saving was estimated in the first year after changing the antiemetic treatment. The present results suggest that DEX alone is equally effective for preventing nausea and vomiting and less expensive compared with a 5-HT(3) receptor antagonist plus DEX in low emetic risk chemotherapy with docetaxel.

A Survey of Restraint Methods for the Safe Transport of Children in Ground Ambulances.

PubMed

Woods, Rashida H; Shah, Manish; Doughty, Cara; Gilchrest, Anthony

2018-03-01

The National Highway Traffic Safety Administration (NHTSA) released draft recommendations in 2010 on the safe transport of children in ground ambulances. The purpose of this study was to assess awareness of these guidelines among emergency medical service (EMS) agencies and to identify implementation barriers. We conducted a cross-sectional, anonymous online survey of 911-responding, ground transport EMS agencies in Texas. Demographics, modes of transport based on case scenarios, and barriers to implementation were assessed. Of 62 eligible EMS agencies that took the survey, 35.7% were aware of the NHTSA guidelines, 62.5% agreed they would improve safety, and 41.1% planned to implement them. Seventy-five percent of EMS agencies used the ideal or acceptable alternative to transport children requiring continuous monitoring, and 69.5% chose ideal or acceptable alternatives for children requiring spinal immobilization. The ideal or acceptable alternative was not chosen for children who were not injured or ill (93.2%), ill or injured but not requiring continuous monitoring (53.3%), and situations when multiple patients required transport (57.6%). The main requirements for implementation were provider education, ambulance interior modifications, new guidelines in the EMS agency, and purchase of new equipment. Few EMS agencies are aware of the NHTSA guidelines on safe transport of children in ground ambulances. Although most agencies appropriately transport children who require monitoring, interventions, or spinal immobilization, they use inappropriate means to transport children in situations with multiple patients, lack of injury or illness, or lack of need for monitoring.

Current challenges in adherence to clinical guidelines for antibiotic prophylaxis in surgery.

PubMed

Khan, Sohail Ahmad; Rodrigues, Gabrial; Kumar, Pramod; Rao, Padma G M

2006-06-01

To study the impact of guidelines on surgical antibiotic prophylaxis in clinical practice, barriers involved in adherence to guidelines and how to overcome the same. Literature pertaining to prophylactic antibiotic usage was searched. Medscape, Medline, Cochrane, Surgical Infection Prevention (SIP) project databases were reviewed. Recent articles from relevant journals, texts, and standard guidelines were also studied. Local guidelines seem more likely to be accepted and followed than those developed nationally. Major barriers involved in adherence to guidelines include lack of awareness about the guidelines, general perception of guideline as a bureaucratic rather than educational tool. Some practitioners perceive guidelines as "cookbook medicine" that does not permit them to make their own medical decisions. Other barriers are complex, multi-step systems that create confusion, decrease accountability. Methods for guideline adherence include surveillance and data analysis, new systems to facilitate documentation and improving workflow, education regarding current evidence-based guidelines and promoting the development of local guidelines or protocol, development and implementation of reminders to facilitate adherence to the local guidelines. A multidisciplinary steering team of surgeons, infectious disease specialists, pharmacists, anesthesiologists, microbiologists and nurses should develop local guidelines suitable to their institution and methods for adherence to prevent the surgical site infections. The gap between evidence-based guidelines and practice must be addressed in order to achieve optimal practice in this domain.

[Implementation of new guidelines for management of prelabour rupture of membranes did not have the desired effect].

PubMed

Kamper, Christina Hjørnet; Hvidman, Lone; Helmig, Rikke Bek

2014-02-03

Many resources are used in developing guidelines for the treatment and handling of different diseases and clinical situations. It is important to evaluate the effect of these guidelines; are they being followed and do they have the desired impact on patient care? This report describes a quality control evaluation of whether the implementation of a new PROM (prelabour rupture of membranes) management guideline at Department Y at the Aarhus University Hospital had the wanted effect on the length of labour, use of prophylactic antibiotics, frequency of neonatal admission and neonatal infection.

Computer-Based Access to Patient Care Guidelines

PubMed Central

Oliver, Diane E.; Estey, Greg; Ford, Penny; Burke, Sheila M.; Teplick, Richard S.; Zielstorff, Rita D.; Barnett, G. Octo

1990-01-01

As health care becomes more complex and expensive, interest in the potential benefits of developing and implementing patient care guidelines has emerged. We propose that a hypertext-based system designed to deal with patient-specific problems can provide a valuable method of access to such guidelines. Because intensive care medicine is one area which has become extraordinarily complex in recent years, we have chosen this as an area in which the need exists for readily accessible expertise. More specifically, in this project we are focusing on the development and implementation of guidelines for troubleshooting problems associated with the of a pulmonary artery catheter.

Automating Guidelines for Clinical Decision Support: Knowledge Engineering and Implementation.

PubMed

Tso, Geoffrey J; Tu, Samson W; Oshiro, Connie; Martins, Susana; Ashcraft, Michael; Yuen, Kaeli W; Wang, Dan; Robinson, Amy; Heidenreich, Paul A; Goldstein, Mary K

2016-01-01

As utilization of clinical decision support (CDS) increases, it is important to continue the development and refinement of methods to accurately translate the intention of clinical practice guidelines (CPG) into a computable form. In this study, we validate and extend the 13 steps that Shiffman et al. 5 identified for translating CPG knowledge for use in CDS. During an implementation project of ATHENA-CDS, we encoded complex CPG recommendations for five common chronic conditions for integration into an existing clinical dashboard. Major decisions made during the implementation process were recorded and categorized according to the 13 steps. During the implementation period, we categorized 119 decisions and identified 8 new categories required to complete the project. We provide details on an updated model that outlines all of the steps used to translate CPG knowledge into a CDS integrated with existing health information technology.

Adherence to the European Society of Cardiology guidelines for the treatment of chronic heart failure

NASA Astrophysics Data System (ADS)

Sitepu, A.; Hamdani, K.

2018-03-01

Heart failure is a tremendous health problem with significant morbidity and mortality. The treatment of heart failure should be applied appropriately to improve the successful management of patients. This study aims to evaluate the adherence to European Society of Cardiology (ESC) guidelines for the treatment of chronic heart failure and to determine factors associated with guideline adherence. This study is an observational study comprising 97 patients with chronic heart failure with reduced ejection fraction. The guideline adherence was assessed the by the use of guideline adherence indicator (GAI), which consider GAI-3 or GAI-5, by calculating the proportion of recommended drugs was prescribed divided by a number of drugs indicated according to the ESC guidelines, in the absence of contraindications. The results showed the use of each indicated drugs were angiotensin- converting enzyme inhibitors or angiotensin receptor blockers (78.4%), beta-blockers (61.9%), mineralocorticoid receptor antagonists (61.9%), diuretics (89.7%), and digitalis (26.8%). Furthermore, the predominant categories of GAI-3 and GAI-5 were moderate. This study demonstrates that the adherence to ESC guidelines for the treatment of chronic heart failure still needs to be improved compared to recent studies. Also, age, etiology of heart failure and comorbidity were associated factors that influence the implementation of ESC guidelines.

Development of tuberculosis infection control guidelines in a pediatric HIV clinic in sub-Saharan Africa.

PubMed

Carlucci, J G; Jin, L; Sanders, J E; Mohapi, E Q; Mandalakas, A M

2015-03-21

A well-established pediatric human immunodeficiency virus (HIV) clinic in Lesotho with initial infection control (IC) measures prioritizing blood-borne disease. In line with international recommendations, services have been expanded to include the management of patients with tuberculosis (TB). The creation of comprehensive IC guidelines with an emphasis on TB has become a priority. To provide a model for developing and implementing IC guidelines in ambulatory care facilities in limited-resource settings with high HIV and TB prevalence. Activities: An IC plan that includes guidance covering both general IC measures and TB-specific guidelines was created by integrating local and international recommendations and emphasizing the importance of administrative measures, environmental controls, and disease-specific precautions. An interdisciplinary committee was established to oversee its implementation, monitoring, and evaluation. Development and implementation of IC guidelines in resource-limited settings are feasible and should be a priority in high HIV and TB prevalence areas. Education should be the cornerstone of such endeavors. Many interventions can be implemented with minimal expertise and material resources. Administrative support and institutional investment are essential to the sustainability of an effective IC program.

A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients.

PubMed

Fox, Timothy R; Li, James; Stevens, Sandra; Tippie, Tracy

2013-09-01

In an effort to reduce prescription opioid abuse originating from our institution, we implement and measure the effect of a prescribing guideline on the rate of emergency department (ED) opioid prescriptions written for patients presenting with dental pain, a complaint previously associated with drug-seeking behavior. After implementing a departmental guideline on controlled substance prescriptions, we performed a structured before-and-after chart review of dental pain patients aged 16 and older. Before the guideline, the rate of opioid prescription was 59% (302/515). After implementation, the rate was 42% (65/153). The absolute decrease in rates was 17% (95% confidence interval 7% to 25%). Additionally, in comparing the 12-month period before and after implementation, the dental pain visit rate decreased from 26 to 21 per 1,000 ED visits (95% confidence interval of decrease 2 to 9 visits/1,000). A performance improvement program involving a departmental prescribing guideline was associated with a reduction in the rate of opioid prescriptions and visits for ED patients presenting with dental pain. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Multistrategy childcare-based intervention to improve compliance with nutrition guidelines versus usual care in long day care services: a study protocol for a randomised controlled trial

PubMed Central

Seward, Kirsty; Finch, Meghan; Wiggers, John; Wyse, Rebecca; Jones, Jannah; Gillham, Karen; Yoong, Sze Lin

2016-01-01

Introduction Interventions to improve child diet are recommended as dietary patterns developed in childhood track into adulthood and influence the risk of chronic disease. For child health, childcare services are required to provide foods to children consistent with nutrition guidelines. Research suggests that foods and beverages provided by services to children are often inconsistent with nutrition guidelines. The primary aim of this study is to assess, relative to a usual care control group, the effectiveness of a multistrategy childcare-based intervention in improving compliance with nutrition guidelines in long day care services. Methods and analysis The study will employ a parallel group randomised controlled trial design. A sample of 58 long day care services that provide all meals (typically includes 1 main and 2 mid-meals) to children while they are in care, in the Hunter New England region of New South Wales, Australia, will be randomly allocated to a 6-month intervention to support implementation of nutrition guidelines or a usual care control group in a 1:1 ratio. The intervention was designed to overcome barriers to the implementation of nutrition guidelines assessed using the theoretical domains framework. Intervention strategies will include the provision of staff training and resources, audit and feedback, ongoing support and securing executive support. The primary outcome of the trial will be the change in the proportion of long day care services that have a 2-week menu compliant with childcare nutrition guidelines, measured by comprehensive menu assessments. As a secondary outcome, child dietary intake while in care will also be assessed. To assess the effectiveness of the intervention, the measures will be undertaken at baseline and ∼6 months postbaseline. Ethics and dissemination The study was approved by the Hunter New England Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications. PMID:27301484

Sexually transmitted disease syndromic case management through public sector facilities: development and assessment study in Punjab Pakistan.

PubMed

Khan, Muhammad Amir; Javed, Wajiha; Ahmed, Maqsood; Walley, John; Munir, Muhammad Arif

2014-01-01

Sexually transmitted infections (STIs) are a priority health problem. We proposed a prospective study in two districts of Punjab, using an intervention package, which included guidelines and protocols on syndrome-based management of STIs, adapted in light of technical guidelines from the National AIDS Control Program and the World Health Organization. The aim of this study was to assess the operational effectiveness of STI case management guidelines and to assess factors that determine the adherence to guidelines for management of STIs at public health facilities in Pakistan. A prospective study lasting 18 months (January 2008 to June 2009), which reviewed early implementation experiences of updated case management guidelines for delivery of syndrome-based STI/reproductive tract infection care, through public-sector health care facilities. The project was implemented in two districts of Punjab, Sargodha and Jhang. A Cox regression model with stratification was done. The prevalence of STI was 26 per 100,000 patients. In women, the reported symptoms were 80% vaginal discharge and 12% abdominal pain. Forty-four percent of men had a genital ulcer and 29% of men had genital discharge. Age of participants ranged from 13 to 60 years. The study comprised 28.6% men and 71.4% women. The majority of the population attending these clinics was from rural areas (70%). The variables independently associated with adherence to guidelines were availability of male paramedic, age of patient, and type of diagnosis made. There was an important interaction (effect modification) present between the area of health facility and patient sex. Screening, diagnosis, and treatment costs for many STIs are expensive and thus an easier, low-cost, syndrome-based public health strategy is the adoption of the proposed STI syndrome case management guidelines. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Representation primitives, process models and patient data in computer-interpretable clinical practice guidelines: a literature review of guideline representation models.

PubMed

Wang, Dongwen; Peleg, Mor; Tu, Samson W; Boxwala, Aziz A; Greenes, Robert A; Patel, Vimla L; Shortliffe, Edward H

2002-12-18

Representation of clinical practice guidelines in a computer-interpretable format is a critical issue for guideline development, implementation, and evaluation. We studied 11 types of guideline representation models that can be used to encode guidelines in computer-interpretable formats. We have consistently found in all reviewed models that primitives for representation of actions and decisions are necessary components of a guideline representation model. Patient states and execution states are important concepts that closely relate to each other. Scheduling constraints on representation primitives can be modeled as sequences, concurrences, alternatives, and loops in a guideline's application process. Nesting of guidelines provides multiple views to a guideline with different granularities. Integration of guidelines with electronic medical records can be facilitated by the introduction of a formal model for patient data. Data collection, decision, patient state, and intervention constitute four basic types of primitives in a guideline's logic flow. Decisions clarify our understanding on a patient's clinical state, while interventions lead to the change from one patient state to another.

Lipid-lowering drugs in ischaemic heart disease: A quasi-experimental uncontrolled before-and-after study of the effectiveness of clinical practice guidelines

PubMed Central

2011-01-01

Background Cardiovascular diseases(CVD), specifically ischaemic heart disease(IHD), are the main causes of death in industrialized countries. Statins are not usually prescribed in the most appropriate way. To ensure the correct prescription of these drugs, it is necessary to develop, disseminate and implement clinical practice guidelines(CPGs), and subsequently evaluate them. The main objective of this study is to evaluate the effectiveness of the implementation of consensual Lipid-lowering drugs (LLD) prescription guidelines in hospital and primary care settings, to improve the control of Low-Density Lipoprotein Cholesterol (LDL-C) levels in patients with IHD in the Terres de l'Ebre region covered by the Catalonian Health Institute. Secondary objectives are to assess the improvement of the prescription profile of these LLDs, to assess cardiovascular morbimortality and the professional profile and participant centre characteristics that govern the control of LDL-C. Methods/Design Design: Quasi-experimental uncontrolled before and after study. The intervention consists of the delivery of training strategies for guideline implementation (classroom clinical sessions and on-line courses) aimed at primary care and hospital physicians. The improvement in the control of LDL-C levels in the 3,402 patients with IHD in our territory is then assessed. Scope: Primary care physicians from 11 basic health areas(BHAs) and two hospital services (internal medicine and cardiology). Sample: 3,402 patients registered with IHD in the database of the Catalan Institute of Health(E-cap) before December 2008 and patients newly diagnosed during 2009-2010. Variables: Percentage of patients achieving good control of LDL-C, measured in milligrams per decilitre. The aim of the intervention is to achieve levels of LDL-C < 100 mg/dl in patients with IHD. Secondary variables measure type and time of diagnosis of IHD, type and dose of prescribed cholesterol-lowering drugs, level of physician participation in training activities and their professional profile. Discussion The development of prescription guidelines previously agreed by various medical specialists involved in treating IHD patients have usually improved drug prescription. The guideline presented in this study aims to improve the control of LDL-C by training physicians through presential and on-line courses on the dissemination of this guideline, and by providing feedback on their personal results a year after this training intervention. PMID:21816068

A practical approach to implementing new CDC GBS guidelines.

PubMed

Hill, Shawna M; Bridges, Margie A; Knudsen, Alexis L; Vezeau, Toni M

2013-01-01

Group beta streptococcus (GBS) is a well-documented pathogen causing serious maternal and fetal morbidity and mortality. The CDC guidelines for managing clients who test positive for GBS in pregnancy were revised and published in 2010. However, CDC and extant literature provide limited guidance on implementation strategies for these new recommendations. Although several algorithms are included in the CDC (2010) document, none combine the maternal risk factors for practical and consistent implementation from pregnancy to newborn. In response to confusion upon initial education of these guidelines, we developed an algorithm for maternal intrapartum management. In addition, we clarified the CDC (2010) newborn algorithm in response to provider request. Without altering the recommendations, both algorithms provide clarification of the CDC (2010) guidelines. The nursing process provides an organizational structure for the discussion of our efforts to translate the complex guidelines into practice. This article could provide other facilities with tools for dealing with specific aspects of the complex clinical management of perinatal GBS.

Protocol for a qualitative synthesis of barriers and facilitators in implementing guidelines for diagnosis of tuberculosis.

PubMed

Ochodo, Eleanor; Kredo, Tamara; Young, Taryn; Wiysonge, Charles Shey

2017-06-09

Despite the introduction of new tests and guidelines for diagnosis of tuberculosis (TB), worldwide case detection rate of TB is still suboptimal. This could be in part explained by the poor implementation of TB diagnostic guidelines. We aim to identify, appraise and synthesise qualitative evidence exploring the barriers and facilitators to implementing TB diagnostic guidelines. A systematic review of qualitative studies will be conducted. Relevant electronic databases will be searched and studies included based on predefined inclusion criteria. We will also search reference lists, grey literature, conduct forward citation searches and contact relevant content experts. An adaptation of the Critical Appraisal Skills Programme tool will be used to assess the methodological quality of included studies. Two authors will review the search output, extract data and assess methodological quality independently, resolving any disagreements by consensus. We will use the thematic framework analysis approach based on the Supporting the Use of Research Evidence thematic framework to analyse and synthesise our data. We will apply the Confidence in the Evidence from Reviews of Qualitative research approach to transparently assess our confidence in the findings of the systematic review. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42016039790 TRIAL REGISTRATION NUMBER: PROSPERO 2016: CRD42016039790. Available from http://www.crd.york.ac.uk/PROSPERO/. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Implementing guidelines on reporting research using animals (ARRIVE etc.): new requirements for publication in BJP

PubMed Central

McGrath, John C; Lilley, Elliot

2015-01-01

The ARRIVE guidelines have been implemented in BJP for 4 years with the aim of increasing transparency in reporting experiments involving animals. BJP has assessed our success in implementing them and concluded that we could do better. This editorial discusses the issues and explains how we are changing our requirements for authors to report their findings in experiments involving animals. This is one of a series of editorials discussing updates to the BJP Instructions to Authors Video To view the video on the ARRIVE guidelines, visit: https://www.youtube.com/watch?v=DYXoUAnhoPM PMID:25964986

Implementation of a two-part unit-based multiple intervention: moving evidence-based practice into action.

PubMed

Rashotte, Judy; Thomas, Margot; Grégoire, Diane; Ledoux, Sheila

2008-06-01

This study examined the impact of a 2-part unit-based multiple intervention on the use by pediatric critical care nurses of best practice guidelines for pressure-ulcer prevention. A total of 23 nurses participated in a repeated-measures design pre- and post-intervention to address 2 questions: Is there a difference in nurses' evidence-based practices following implementation of an educational intervention only versus implementation of both an educational and an innovative intervention? Are the changes sustained 6 months after completion of the intervention? A significant change occurred in the implementation of 2 of 11 recommended practices following both interventions: assessment of risk of pressure ulcers using an age-appropriate tool (p < or = 0.001), and the documentation of same (p < or = 0.001). These changes may have been sustained. The findings bring to light the real challenges encountered when attempting to implement and evaluate multiple knowledge translation strategies associated with complex best practice guidelines in clinical practice.

The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children.

PubMed

Waddell, Danielle; McGrath, Ian; Maude, Phil

2014-07-01

This study evaluated the use and effect of a rapid rehydration guideline for the management of gastroenteritis in children 6months to 4years of age in an Emergency Department (ED). The guideline aims to facilitate rehydration within 4h of arrival to the ED, using oral or nasogastric fluids. Primary outcome measures were ED Length of Stay (LOS) and hospital admission rates. Documentation of physiological recovery and consistency of re-hydration regimes used were examined as secondary outcomes. A quasi-experimental design using the medical records of 235 children pre and post intervention was used. Descriptive statistics (frequencies, medians, interquartile ranges) were used to summarize the data. The pre and post-test groups were compared using Chi Square and the Mann Whitney U Test. There was an increase in the ED LOS and in hospital admission rates post implementation of the rapid rehydration guideline in the ED. However, the time frame for initiation of rehydration therapy using oral or nasogastric routes improved post guideline implementation. The need for improvements in the ED management of dehydration secondary to gastroenteritis has been highlighted providing potential benefits to patient care and outcomes. Copyright © 2013 Elsevier Ltd. All rights reserved.

Refining a taxonomy for guideline implementation: results of an exercise in abstract classification

PubMed Central

2013-01-01

Background To better understand the efficacy of various implementation strategies, improved methods for describing and classifying the nature of these strategies are urgently required. The aim of this study was to develop and pilot the feasibility of a taxonomy to classify the nature and content of implementation strategies. Methods A draft implementation taxonomy was developed based on the Cochrane Effective Practice and Organisation of Care (EPOC) data collection checklist. The draft taxonomy had four domains (professional, financial, organisational and regulatory) covering 49 distinct strategies. We piloted the draft taxonomy by using it to classify the implementation strategies described in the conference abstracts of the implementation stream of the 2010 Guideline International Network Conference. Five authors classified the strategies in each abstract individually. Final categorisation was then carried out in a face-to-face consensus meeting involving three authors. Results The implementation strategies described in 71 conference abstracts were classified. Approximately 15.5% of abstracts utilised strategies that could not be categorised using the draft taxonomy. Of those strategies that could be categorised, the majority were professionally focused (57%). A total of 41% of projects used only one implementation strategy, with 29% using two and 31% three or more. The three most commonly used strategies were changes in quality assurance, quality improvement and/or performance measurement systems, changes in information and communication technology, and distribution of guideline materials (via hard-copy, audio-visual and/or electronic means). Conclusions Further refinement of the draft taxonomy is required to provide hierarchical dimensions and granularity, particularly in the areas of patient-focused interventions, those concerned with audit and feedback and quality improvement, and electronic forms of implementation, including electronic decision support. PMID:23497520

Refining a taxonomy for guideline implementation: results of an exercise in abstract classification.

PubMed

Mazza, Danielle; Bairstow, Phillip; Buchan, Heather; Chakraborty, Samantha Paubrey; Van Hecke, Oliver; Grech, Cathy; Kunnamo, Ilkka

2013-03-15

To better understand the efficacy of various implementation strategies, improved methods for describing and classifying the nature of these strategies are urgently required. The aim of this study was to develop and pilot the feasibility of a taxonomy to classify the nature and content of implementation strategies. A draft implementation taxonomy was developed based on the Cochrane Effective Practice and Organisation of Care (EPOC) data collection checklist. The draft taxonomy had four domains (professional, financial, organisational and regulatory) covering 49 distinct strategies. We piloted the draft taxonomy by using it to classify the implementation strategies described in the conference abstracts of the implementation stream of the 2010 Guideline International Network Conference. Five authors classified the strategies in each abstract individually. Final categorisation was then carried out in a face-to-face consensus meeting involving three authors. The implementation strategies described in 71 conference abstracts were classified. Approximately 15.5% of abstracts utilised strategies that could not be categorised using the draft taxonomy. Of those strategies that could be categorised, the majority were professionally focused (57%). A total of 41% of projects used only one implementation strategy, with 29% using two and 31% three or more. The three most commonly used strategies were changes in quality assurance, quality improvement and/or performance measurement systems, changes in information and communication technology, and distribution of guideline materials (via hard-copy, audio-visual and/or electronic means). Further refinement of the draft taxonomy is required to provide hierarchical dimensions and granularity, particularly in the areas of patient-focused interventions, those concerned with audit and feedback and quality improvement, and electronic forms of implementation, including electronic decision support.

Implementation Interventions Used in Nursing Homes and Hospitals: A Descriptive, Comparative Study between Austria, Germany, and The Netherlands.

PubMed

Breimaier, Helga E; Halfens, Ruud J G; Wilborn, Doris; Meesterberends, Esther; Haase Nielsen, Gunnar; Lohrmann, Christa

2013-01-01

Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.

Homework in Physical Education: Benefits and Implementation

ERIC Educational Resources Information Center

Novak, Benjamin Edward; Lynott, Francis John, III.

2015-01-01

This article identifies homework as an underutilized strategy in physical education. It reviews the benefits associated with the use of homework in the physical education setting, and provides guidelines for the effective implementation of this strategy. The guidelines include practical application examples and define structured active homework…

78 FR 16783 - Approval and Promulgation of Implementation Plans; Georgia; Control Techniques Guidelines and...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-19

... Promulgation of Implementation Plans; Georgia; Control Techniques Guidelines and Reasonably Available Control...), related to reasonably available control technology (RACT) requirements. This correcting amendment corrects... October 21, 2009, SIP submittal for certain source categories for which EPA has issued control technique...

75 FR 59179 - Approval and Promulgation of Air Quality Implementation Plans; Maryland; Adoption of Control...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-27

... (RACT) for sources covered by EPA's Control Techniques Guidelines (CTG) for flexible packaging printing... Promulgation of Air Quality Implementation Plans; Maryland; Adoption of Control Techniques Guidelines for Flexible Packaging Printing AGENCY: Environmental Protection Agency (EPA). ACTION: Proposed rule. SUMMARY...

Guidelines for preventing common medical complications of catatonia: case report and literature review.

PubMed

Clinebell, Kimberly; Azzam, Pierre N; Gopalan, Priya; Haskett, Roger

2014-06-01

Comprehensive hospital-based care for individuals with catatonia relies on preventive approaches to reduce medical morbidity and mortality. Without syndrome-specific guidelines, psychiatrists must draw from measures used for general medical and surgical inpatients. We employ a prototypical case to highlight medical complications of catatonia and review preventive guidelines for implementation in the inpatient setting. Searches of the PubMed and Ovid databases were conducted from September-November 2013 using keywords relevant to 4 medical complications of catatonia: deep vein thrombosis/pulmonary embolism, pressure ulcers, muscle contractures, and nutritional deficiencies. A complementary general web-browser search was performed to help ensure that unpublished guidelines were considered. A search for deep vein thrombosis/pulmonary embolism guidelines yielded 478 articles that were appraised for relevance, and 6 were chosen for review; the pressure ulcer guideline search yielded 5,665 articles, and 5 were chosen; the muscle contractures guideline search yielded 1,481 articles, and 3 were chosen; and the nutritional deficiencies guideline search yielded 16,937 articles, and 4 were chosen. Guidelines were reviewed for content and summarized in a manner relevant to the audience. No quantitative analyses were conducted. Guidelines for deep vein thrombosis/pulmonary embolism prophylaxis support use of anticoagulant therapies for patients with catatonia who are at lower risk for acute bleeding. Pressure ulcer prevention hinges on frequent skin evaluation, use of support surfaces, and repositioning. Muscle contracture data are less clear and must be extrapolated from studies of patients with neurologic injuries. Early initiation of enteral nutrition should be considered in patients with prolonged immobility. As medical complications are common with catatonia, implementation of preventive measures is imperative. © Copyright 2014 Physicians Postgraduate Press, Inc.

EVALUATION GUIDELINES FOR ECOLOGICAL INDICATORS

EPA Science Inventory

This document presents fifteen technical guidelines to evaluate the suitability of an ecological indicator for a particular monitoring program. The guidelines are organized within four evaluation phrases: conceptual relevance, feasibility of implementation, response variability...

41 CFR 101-27.102-2 - Guidelines.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Replenishment § 101-27.102-2 Guidelines. Guidelines for implementing the EOQ principle of stock replenishment are in the GSA Handbook, The Economic Order Quantity Principle and Applications, issued by the Federal...

Design guidelines for robotically serviceable hardware

NASA Technical Reports Server (NTRS)

Gordon, Scott A.

1988-01-01

Research being conducted at the Goddard Space Flight Center into the development of guidelines for the design of robotically serviceable spaceflight hardware is described. A mock-up was built based on an existing spaceflight system demonstrating how these guidelines can be applied to actual hardware. The report examines the basic servicing philosophy being studied and how this philosophy is reflected in the formulation of design guidelines for robotic servicing. A description of the mock-up is presented with emphasis on the design features that make it robot friendly. Three robotic servicing schemes fulfilling the design guidelines were developed for the mock-up. These servicing schemes are examined as to how their implementation was affected by the constraints of the spacecraft system on which the mock-up is based.

5 CFR 724.403 - Advisory guidelines.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 5 Administrative Personnel 2 2011-01-01 2011-01-01 false Advisory guidelines. 724.403 Section 724... (CONTINUED) IMPLEMENTATION OF TITLE II OF THE NOTIFICATION AND FEDERAL EMPLOYEE ANTIDISCRIMINATION AND RETALIATION ACT OF 2002 Best Practices § 724.403 Advisory guidelines. OPM will issue advisory guidelines to...

5 CFR 724.403 - Advisory guidelines.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 5 Administrative Personnel 2 2013-01-01 2013-01-01 false Advisory guidelines. 724.403 Section 724... (CONTINUED) IMPLEMENTATION OF TITLE II OF THE NOTIFICATION AND FEDERAL EMPLOYEE ANTIDISCRIMINATION AND RETALIATION ACT OF 2002 Best Practices § 724.403 Advisory guidelines. OPM will issue advisory guidelines to...

5 CFR 724.403 - Advisory guidelines.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 5 Administrative Personnel 2 2014-01-01 2014-01-01 false Advisory guidelines. 724.403 Section 724... (CONTINUED) IMPLEMENTATION OF TITLE II OF THE NOTIFICATION AND FEDERAL EMPLOYEE ANTIDISCRIMINATION AND RETALIATION ACT OF 2002 Best Practices § 724.403 Advisory guidelines. OPM will issue advisory guidelines to...

5 CFR 724.403 - Advisory guidelines.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 5 Administrative Personnel 2 2012-01-01 2012-01-01 false Advisory guidelines. 724.403 Section 724... (CONTINUED) IMPLEMENTATION OF TITLE II OF THE NOTIFICATION AND FEDERAL EMPLOYEE ANTIDISCRIMINATION AND RETALIATION ACT OF 2002 Best Practices § 724.403 Advisory guidelines. OPM will issue advisory guidelines to...

A Cluster-randomized Trial of a Centralized Clinical Pharmacy Cardiovascular Risk Service to Improve Guideline Adherence

PubMed Central

Carter, Barry L.; Coffey, Christopher S.; Chrischilles, Elizabeth A.; Ardery, Gail; Ecklund, Dixie; Gryzlak, Brian; Vander Weg, Mark W.; James, Paul A.; Christensen, Alan J.; Parker, Christopher P.; Gums, Tyler; Finkelstein, Rachel J; Uribe, Liz; Polgreen, Linnea A.

2015-01-01

Background Numerous studies have demonstrated the value of including pharmacists in team-based care to improve adherence to cardiovascular (CV) guidelines, medication adherence and risk factor control but there is limited information on whether these models can be successfully implemented more widely in diverse settings and populations. The purpose of this study is to evaluate whether a centralized, web-based CV risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in multiple primary care medical offices with diverse geographic and patient characteristics. Methods This study is a prospective trial in 20 primary care offices stratified by the percent of under-represented minorities and then randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. The primary outcome is the difference in guideline adherence between groups. Data will also be abstracted from the medical record at 24 months to determine if the intervention effect is sustained after it is discontinued. Conclusions This study expects to enroll subjects through 2016 with results expected in 2019. This study will provide information on whether a distant, centralized CV risk service can be implemented in large numbers of medical offices, if it is effective in diverse populations, and if the effect can be sustained long-term. PMID:26111939

Applying the knowledge to action framework to plan a strategy for implementing breast cancer screening guidelines: an interprofessional perspective.

PubMed

Munce, Sarah; Kastner, Monika; Cramm, Heidi; Lal, Shalini; Deschêne, Sarah-Maude; Auais, Mohammad; Stacey, Dawn; Brouwers, Melissa

2013-09-01

Integrated knowledge translation (IKT) interventions may be one solution to improving the uptake of clinical guidelines. IKT research initiatives are particularly relevant for breast cancer research and initiatives targeting the implementation of clinical guidelines and guideline implementation initiatives, where collaboration with an interdisciplinary team of practitioners, patients, caregivers, and policy makers is needed for producing optimum patient outcomes. The objective of this paper was to describe the process of developing an IKT strategy that could be used by guideline developers to improve the uptake of their new clinical practice guidelines on breast cancer screening. An interprofessional group of students as well as two faculty members met six times over three days at the KT Canada Summer Institute in 2011. The team used all of the phases of the action cycle in the Knowledge to Action Framework as an organizing framework. While the entire framework was used, the step involving assessing barriers to knowledge use was judged to be particularly relevant in anticipating implementation problems and being able to inform the specific KT interventions that would be appropriate to mitigate these challenges and to accomplish goals and outcomes. This activity also underscored the importance of group process and teamwork in IKT. We propose that an a priori assessment of barriers to knowledge use (i.e., level and corresponding barriers), along with the other phases of the Knowledge to Action Framework, is a strategic approach for KT strategy development, implementation, and evaluation planning and could be used in the future planning of KT strategies.

Adopting and implementing nutrition guidelines in recreational facilities: tensions between public health and corporate profitability.

PubMed

Olstad, Dana Lee; Raine, Kim D; McCargar, Linda J

2013-05-01

Little is known about how public entities can partner with industry to achieve public health goals. We investigated industry's perspective of factors that influenced their adoption and implementation of voluntary, government-issued nutrition guidelines (Alberta Nutrition Guidelines for Children and Youth, ANGCY) in recreational facilities. In-depth semi-structured interviews were conducted. Data were analysed using directed content analysis. Food services in recreational facilities. Seven managers from industry participated; five from companies that had adopted and implemented the ANGCY (adopters) in recreational facilities and two from companies that had not (non-adopters). Industry views nutrition guidelines through the lens of profitability. Non-adopters were unwilling to implement the ANGCY for fear of sacrificing short-term profitability, whereas adopters adhered to them in an attempt to position themselves for long-term profitability. Adopters faced barriers including few resources, no training, complex guidelines, low availability of and demand for ANGCY-compliant products, competitive pressures and substantial declines in revenue. Managers believed widespread voluntary adoption of the ANGCY was unlikely without government incentives and/or a mandate, as the environmental context for voluntary action was poor. All managers supported government-mandated implementation of the ANGCY to level the playing field upon which companies compete. Public-private partnerships in recreational facilities can embrace public health goals in the short term, provided industry perceives potential for long-term financial gain. Widespread uptake of voluntary nutrition guidelines in this setting is unlikely, however, as market mechanisms do not encourage industry to sell and promote healthier options. Government legislation may therefore be warranted.

Implementation in Indonesia of the WHO Pocket Book of Hospital Care for Children.

PubMed

Li, Michelle Y; Puspita, Ratih; Duke, Trevor; Agung, Fransisca H; Hegar, Badriul; Pritasari, Kirana; Weber, Martin W

2014-05-01

Effective implementation of evidence-based practice guidelines has the potential to improve quality of hospital care for children. To achieve this in Indonesia, a locally adapted version of the WHO Pocket Book of Hospital Care for Children was published in 2009. To document implementation of the Pocket Book in Indonesia and to compare uptake in health facilities in which there has been a quality-improvement approach involving audit and feedback with uptake in settings in which there has been only passive dissemination. Indonesian district health offices, district hospitals, health centres with beds, and medical schools were surveyed by telephone, and an online and telephone survey of paediatricians was conducted. Health facilities in four provinces were visited, and key stakeholders were interviewed. Health facilities were assessed on availability of the guidelines, use by staff, and their incorporation into hospital procedures and activities. There was evidence of use of the Pocket Book across Indonesia, despite limited funding for implementation. Its distribution had reached all provinces; 61% (33/54) of health facilities surveyed had a copy of the guidelines. Hospitals involved in a related quality audit were more likely to report use of the guidelines than hospitals exposed to passive dissemination, although this difference was not significant. Of 150 paediatricians sampled, 109 (73%) reported referring to the guidelines in their clinical practice. The guidelines have been incorporated into the postgraduate paediatric curriculum in four of 13 universities sampled. There was encouraging evidence of uptake of the Pocket Book in Indonesia following local adaptation, nationwide mailing distribution and small-scale local implementation activities.

Comparing a Mobile Decision Support System Versus the Use of Printed Materials for the Implementation of an Evidence-Based Recommendation: Protocol for a Qualitative Evaluation.

PubMed

Camacho, Jhon; Medina Ch, Ana María; Landis-Lewis, Zach; Douglas, Gerald; Boyce, Richard

2018-04-13

The distribution of printed materials is the most frequently used strategy to disseminate and implement clinical practice guidelines, although several studies have shown that the effectiveness of this approach is modest at best. Nevertheless, there is insufficient evidence to support the use of other strategies. Recent research has shown that the use of computerized decision support presents a promising approach to address some aspects of this problem. The aim of this study is to provide qualitative evidence on the potential effect of mobile decision support systems to facilitate the implementation of evidence-based recommendations included in clinical practice guidelines. We will conduct a qualitative study with two arms to compare the experience of primary care physicians while they try to implement an evidence-based recommendation in their clinical practice. In the first arm, we will provide participants with a printout of the guideline article containing the recommendation, while in the second arm, we will provide participants with a mobile app developed after formalizing the recommendation text into a clinical algorithm. Data will be collected using semistructured and open interviews to explore aspects of behavioral change and technology acceptance involved in the implementation process. The analysis will be comprised of two phases. During the first phase, we will conduct a template analysis to identify barriers and facilitators in each scenario. Then, during the second phase, we will contrast the findings from each arm to propose hypotheses about the potential impact of the system. We have formalized the narrative in the recommendation into a clinical algorithm and have developed a mobile app. Data collection is expected to occur during 2018, with the first phase of analysis running in parallel. The second phase is scheduled to conclude in July 2019. Our study will further the understanding of the role of mobile decision support systems in the implementation of clinical practice guidelines. Furthermore, we will provide qualitative evidence to aid decisions made by low- and middle-income countries' ministries of health about investments in these technologies. ©Jhon Camacho, Ana María Medina Ch, Zach Landis-Lewis, Gerald Douglas, Richard Boyce. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 13.04.2018.

The effect of an e-learning supported Train-the-Trainer programme on implementation of suicide guidelines in mental health care.

PubMed

de Beurs, Derek P; de Groot, Marieke H; de Keijser, Jos; Mokkenstorm, Jan; van Duijn, Erik; de Winter, Remco F P; Kerkhof, Ad J F M

2015-04-01

Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline. 45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments. Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found. The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study. Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients. Netherlands Trial Register (NTR3092 www.trialregister.nl). Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.

Do guidelines influence the implementation of health programs? — Uganda’s experience

PubMed Central

2012-01-01

Background A guideline contains processes and procedures intended to guide health service delivery. However, the presence of guidelines may not guarantee their implementation, which may be a result of weaknesses in the development process. This study was undertaken to describe the processes of developing health planning, services management, and clinical guidelines within the health sector in Uganda, with the goal of understanding how these processes facilitate or abate the utility of guidelines. Methods Qualitative and quantitative research methods were used to collect and analyze data. Data collection was undertaken at the levels of the central Ministry of Health, the district, and service delivery. Qualitative methods included review of documents, observations, and key informant interviews, as well as quantitative aspects included counting guidelines. Quantitative data were analyzed with Microsoft Excel, and qualitative data were analyzed using deductive content thematic analysis. Results There were 137 guidelines in the health sector, with programs related to Millennium Development Goals having the highest number (n = 83). The impetus for guideline development was stated in 78% of cases. Several guidelines duplicated content, and some conflicted with each other. The level of consultation varied, and some guidelines did not consider government-wide policies and circumstances at the service delivery level. Booklets were the main format of presentation, which was not tailored to the service delivery level. There was no framework for systematic dissemination, and target users were defined broadly in most cases. Over 60% of guidelines available at the central level were not available at the service delivery level, but there were good examples in isolated cases. There was no framework for systematic monitoring of use, evaluation, and review of guidelines. Suboptimal performance of the supervision framework that would encourage the use of guidelines, assess their utilization, and provide feedback was noted. Conclusions Guideline effectiveness is compromised by the development process. To ensure the production of high-quality guidelines, efforts must be employed at the country and regional levels. The regional level can facilitate pooling resources and expertise in knowledge generation, methodology development, guideline repositories, and capacity building. Countries should establish and enforce systems and guidance on guideline development. PMID:23068082