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PubMed2004

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews.

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.

Female↗

PubMed2001

Implementing the Galasko Report on the management of head injuries: the Eastern Region approach.

OBJECTIVES: The Royal College of Surgeons (RCS) Report on the management of patients with head injuries under the chairmanship of Professor Galasko, published in June 1999, made important recommendations that will have a profound effect on the organisation of management of head injuries and major implications for resources. The Eastern Region carried out an audit study to determine the provision of current services available, to assess the shortfall and likely resource implications for the implementation of the report and hence lay the foundations for a strategic plan for change across the region. METHODOLOGY: A series of interviews with all 20 accident and emergency (A&E) departments across the Eastern Region and the two regional neuroscience units (RNU) was undertaken. The results of the survey and the implications of the implementation were fed back to and discussed at a multidisciplinary regional seminar. RESULTS: There is considerable variation and major deficiencies in the service provision currently available for the management of head injuries in the Eastern Region. There are major deficiencies in A&E resources, care of moderate head injuries and rehabilitation and follow up of patients. There is a significant shortfall in resources for the implementation of the recommendations. CONCLUSION: There are major deficiencies in the overall management of head injuries. Although the RCS Galasko Report recommendations were agreed to be very desirable, they cannot be implemented without a large increase in resources in terms of funding, staffing and training.

Craniocerebral Trauma↗

PubMed2002

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance.

OBJECTIVES: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. DESIGN: Qualitative case studies using semi-structured interviews and documentation review. SETTING: Twelve purposively sampled PCG/Ts in England. PARTICIPANTS: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. MAIN OUTCOME MEASURES: Participants' perceptions of the role of clinical governance in PCG/Ts. RESULTS: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). CONCLUSION: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Attitude of Health Personnel↗

PubMed1999

A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines.

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.

Diffusion of Innovation↗

PubMed1999

The passage and initial implementation of Oregon's Measure 44.

OBJECTIVE: To prepare a history of the passage and early implementation of Ballot Measure 44, "An Act to Support the Oregon Health Plan", and tobacco control policymaking in Oregon. Measure 44 raised cigarette taxes in Oregon by US$0.30 per pack, and dedicated 10% of the revenues to tobacco control. METHODS: Data were gathered from interviews with members of the Committee to Support the Oregon Health Plan, Measure 44's campaign committee, as well as with state and local officials, and tobacco control advocates. Additional information was obtained from public documents, internal memoranda, and news reports. RESULTS: Although the tobacco industry outspent Measure 44's supporters 7 to 1, the initiative passed with 56% of the vote. Even before the election, tobacco control advocates were working to develop an implementation plan for the tobacco control programme. They mounted a successful lobbying campaign to see that the legislature did not divert tobacco control funds to other uses. They also stopped industry efforts to limit the scope of the programme. The one shortcoming of the tobacco control forces was not getting involved in planning the initiative early enough to influence the amount of money that was devoted to tobacco control. Although public health groups provided 37% of the money it cost to pass Measure 44, only 10% of revenues were devoted to tobacco control. CONCLUSIONS: Proactive planning and aggressive implementation can secure passage of tobacco control initiatives and see that the associated implementing legislation follows good public health practice.

Health Promotion↗

PubMed2005

Report on the Dutch consensus development meeting for implementation and further development of population screening for colorectal cancer based on FOBT.

A consensus development meeting was held to evaluate whether or not in the Netherlands all requirements were fulfilled for implementation of population screening with FOBT for colorectal cancer, or whether consensus was present that fulfilment by additional research or organisational actions could be obtained within 2-3 years. There was consensus that all classical Wilson and Jungner (1968) criteria, and six additional ones added more recently, had already been fulfilled or could be fulfilled within 2-3 years. Consequently, it was concluded that a national population screening for colorectal cancer should be implemented and carried out in the Netherlands in line with current national and European cancer screening programmes. A list of organisational actions to be taken was established. Research that is needed before the actual national launch of the screening within 2-3 years has been defined. Priorities have to be set for research and organisational actions for the coming 2-3 years for the implementation of population screening. In addition, research suggestions have been defined for the next 10-15 years for evaluation and/or improvement of implemented FOBT screening, and for future screening methodology. It was considered essential that infrastructure for future research would be embedded in the screening programme. A project group to arrange this should be formed.

Adenoma↗

PubMed2006

Improved time intervals by implementation of computerized physician order entry-based stroke team approach.

BACKGROUND: The need for rapid evaluation and treatment of acute stroke patients has been well documented. A computerized physician order entry (CPOE) system can improve communication and provide immediate access to information, which may be useful for an effective team approach program targeted to reduce in-hospital time delays. METHODS: To reduce the time from a patient's arrival at the emergency department to thrombolysis, a team approach program using CPOE was developed, and its efficacy was investigated by comparing time intervals from arrival to evaluation and intravenous tissue-type plasminogen activator (tPA) treatment before and after the implementation of the program. RESULTS: Among 379 consecutive patients who were screened as potential candidates for thrombolysis, 25 patients (6.6%) received tPA during a 1-year period after initiation of the program. Fourteen patients were treated with tPA in the previous year. After program implementation, time from arrival to computed tomography scan was reduced from 34 to 19 min (p = 0.01). Time to report of complete blood count was also shortened from 52 to 33 min (p < 0.01). Finally, time from arrival to tPA treatment was reduced by 23 min (from 79 to 56 min; p < 0.01). Onset-to-door time tended to be longer after the program implementation (from 41 to 60 min; p = 0.14). CONCLUSIONS: Implementation of the CPOE-based team approach program significantly reduced time from emergency department arrival to evaluations and treatment.

Acute Disease↗

PubMed1999

Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning.

We prospectively investigated the large-scale implementation of a respiratory-therapist-driven protocol (TDP) that included 117 respiratory care practitioners (RCPs) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation. During a 12-mo period, we reintroduced a previously validated protocol that included a daily screen (DS) coupled with spontaneous breathing trials (SBTs) and physician prompt, as a TDP without daily input from a physician or "weaning team." With graded, staged educational interventions at 2-mo intervals, RCPs had a 97% completion rate and a 95% correct interpretation rate for the DS. The frequency with which patients who passed the DS underwent SBTs increased throughout the implementation process (p < 0.001). As the year progressed, RCPs more often considered SBTs once patients had passed a DS (p < 0.001), and physicians ordered more SBTs (46 versus 65%, p = 0.004). Overall, SBTs were ordered more often on the medicine than on the surgical services (81 versus 63%, p = 0.001), likely reflecting medical intensivists' prior use of this protocol. Important barriers to protocol compliance were identified through a questionnaire (89 respondents, 76%), and included: Physician unfamiliarity with the protocol, RCP inconsistency in seeking an order for an SBT from the physician, specific reasons cited by the physician for not advancing the patient to a SBT, and lack of stationary unit assignments by RCPs performing the protocol. We conclude that implementation of a validated weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team. RCPs can appropriately perform and interpret DS data more than 95% of the time, but significant barriers to SBTs exist. Through a staged implementation process, using periodic reinforcement of all participants in ventilator management, improved compliance with this large-scale weaning protocol can be achieved.

Clinical Protocols↗

PubMedDate not supplied

Comparison of burnout among medical residents before and after the implementation of work hours limits.

OBJECTIVE: The authors assess whether implementation of work hour limits is associated with a lower prevalence of medical resident burnout. METHOD: A survey was mailed to medical residents in different medical specialties at one university. RESULTS: Somewhat lower burnout prevalence was reported among residents after implementation of work hour limits compared with the rates prior to the implementation period. The decrease in burnout prevalence occurred primarily among PGY-1 residents. Prevalence of burnout increased with hours worked. CONCLUSIONS: Implementing work hour limits appeared to reduce burnout prevalence.

Burnout, Professional↗

PubMed2001

Implementing dual diagnosis services for clients with severe mental illness.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Counseling↗

PubMed2004

The development and implementation of case management for substance use disorders in North America and Europe.

Because of the multifaceted, chronic, and relapsing nature of substance use disorders, case management has been adapted to work with persons who have these disorders. Deliberate implementation has been identified as a powerful determinant of successful case management. This article focuses on six key questions about implementation of case management services on the basis of a comparison of experiences from the United States, the Netherlands, and Belgium. It was found that case management has been applied in various populations with substance use disorders, and distinct models have been associated with positive effects, such as increased treatment participation and retention, greater use of services, and beneficial drug-related outcomes. Program fidelity, robust implementation, extensive training and supervision, administrative support, a team approach, integration in a comprehensive network of services, and minimal continuity have all been linked to successful implementation.

Case Management↗

PubMed2006

State mental health policy: statewide implementation of the crisis intervention team program: the Ohio model.

This column discusses ways that states can implement community-based best practices statewide, by using the crisis intervention team (CIT) model as an example. Although state mental health authorities may want to use a top-down approach to ensure uniform, high-quality implementation, programs may be more likely to succeed if they arise as bottom-up, grassroots innovations. Programs like CIT are especially challenging to implement because they involve collaboration between complex systems and affect multiple stakeholders. The column describes lessons learned in Ohio in hopes of assisting other states in implementing this and other innovations.

Benchmarking↗

PubMed1998

Replicated declines in assault rates after implementation of the Assaulted Staff Action Program.

A program to address the psychological sequelae of patients' assaults on psychiatric health care staff--the Assaulted Staff Action Program (ASAP)--was previously shown to be associated with a notable decline in the assault rate at the state hospital where it was implemented. This study examined whether these findings would be replicated when ASAP was introduced at three additional state hospitals. Assault rates during the three months before implementation were compared with rates in the first four quarters after implementation. Each facility reported a similar significant decline in rates during the first quarter after implementation and no additional declines in the next three quarters.

Adult↗

PubMed1991

Identifying students with learning disabilities: the effect of implementing statewide guidelines.

Methods for identifying students with learning disabilities continue to be an area of controversy. The present investigation examined the impact of implementing statewide guidelines for the identification of these students. Data were collected from multidisciplinary team reports on 718 students with learning disabilities who were referred and labeled during the 1983-84 school year (before implementation of statewide learning disability guidelines) and 790 students who were identified during 1987-88 (after implementation of the guidelines). The results of the study revealed that the statewide guidelines significantly changed the characteristics of students who were identified. After the implementation of the guidelines, students with much more severe academic problems were identified. These students were much more likely to have a severe discrepancy and be chronically failing in the regular classroom. However, even with explicit, widely accepted guidelines, approximately one third of all students identified in 1987-88 failed to meet the stated criteria for identification. The implications of these findings for professional practice and future research are discussed.

Achievement↗

PubMedDate not supplied

Using a primary nurse manager to implement DCCT recommendations in a large pediatric program.

PURPOSE: This study was conducted to determine whether recommendations from the Diabetes Control and Complications Trial (DCCT) could be implemented in a large pediatric population using a diabetes clinical nurse specialist program coordinator dedicated to intensive management. METHODS: Patients' charts were reviewed to examine HbA1c levels from before the results of the DCCT were published and again 1 year after the recommendations were implemented. Patients who met the following criteria (N = 124) were enrolled: type 1 diabetes, less than 18 years old, followed at Yale for 1 year prior to the results of the DCCT and 1 year after, and HbA1c level recorded in the medical chart. RESULTS: HbA1c levels were significantly lower 1 year after implementing the DCCT protocol; 3 years later these same patients improved even further as evidenced by another decrease in HbA1c levels. The patients were taking more insulin (more Ultralente and regular insulin and less NPH) and had an increased number of injections at both the 1-year and 3-year follow-up points. CONCLUSIONS: The DCCT protocol can be implemented in a large population of pediatric patients with the help of a nurse who is dedicated and available to the patients for ongoing adjustments and provides creative ways to overcome the barriers to achieving normoglycemia.

Adolescent↗

PubMed2003

The effects of mindset on behavior: self-regulation in deliberative and implemental frames of mind.

The effects of deliberative and implemental mindsets--cognitive and motivational states associated with predecisional and postdecisional frames of mind, respectively--were examined in the context of the self-regulation of behavior. Participants who had been induced to deliberate the merits of participating in a specified task formulated more pessimistic expectations about this task than did participants who had been induced to imagine implementing a plan to complete the task. Moreover, participants in the deliberation condition underperformed relative to the participants in the implemental condition, demonstrating that deliberative and implemental thinking can influence behavior as well as cognition.

Affect↗

PubMedDate not supplied

Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit.

BACKGROUND: Despite the evidence that enteral feeding reduces morbidity in critically ill patients and is preferred to parenteral nutrition, the delivery of enteral nutrition (EN) is often inadequate. The purpose of this study was to determine whether implementation of an evidence-based nutrition support (NS) protocol could improve EN delivery. METHODS: An NS protocol incorporating available scientific evidence; data from a retrospective survey of 30 intensive care unit (ICU) patients; and input from dietitians, intensive care physicians, surgeons, nurses, and pharmacists was developed. The impact of this protocol was evaluated prospectively in 123 consecutive adult patients admitted to a multisystem ICU who were eligible for EN. RESULTS: The percentage of patients who received at least 80% of their estimated energy requirements during their ICU stay increased from 20% before implementation of the NS protocol to 60% after implementation (p < .001). After adjusting for confounders, those in the postimplementation group received significantly more kcal/kg/d than the preimplementation group (3.71 kcal/kg/d; 95% confidence interval, 1.64 to 5.78; p = .001). Parenteral nutrition use [corrected] was reduced in the postimplementation group (1.6 vs 13%, p = .02). There was no difference in time to initiation of enteral nutrition between groups (1.76 days preprotocol vs 1.44 days postprotocol implementation, p = .9). CONCLUSIONS: The development and use of an evidence-based NS protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements.

Cohort Studies↗

PubMed1984

Simultaneous algebraic reconstruction technique (SART): a superior implementation of the art algorithm.

In this paper we have discussed what appears to be a superior implementation of the Algebraic Reconstruction Technique (ART). The method is based on 1) simultaneous application of the error correction terms as computed by ART for all rays in a given projection; 2) longitudinal weighting of the correction terms back-distributed along the rays; and 3) using bilinear elements for discrete approximation to the ray integrals of a continuous image. Since this implementation generates a good reconstruction in only one iteration, it also appears to have a computational advantage over the more traditional implementation of ART. Potential applications of this implementation include image reconstruction in conjunction with ray tracing for ultrasound and microwave tomography in which the curved nature of the rays leads to a non-uniform ray density across the image.

Humans↗