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PubMedDate not supplied

Implementing 12-hour shifts on a cardiology nursing development unit.

This article, the first of two parts, discusses the implementation of 12-hour shifts using a locally devised nursing development unit (NDU) framework. A literature review and force-field analysis were undertaken to plan, implement and evaluate the introduction of the 12-hour system. The literature review identified five broad categories: effect on care delivery; nurse education; cost-effectiveness; impact on staff; and implementation strategies. It also ascertained that the most successful methods of implementation were those that gained the cooperation of staff. The force-field analysis identified the restraining forces (e.g. tiredness, the European Working Time Directive and staff views) and therefore allowed the change agent to concentrate his limited time on combating these restraining forces. The second part of this series will examine the evaluation and audit of the 12-hour shift system.

Cardiology Service, Hospital↗

PubMed2006

Barriers to implementing an integrated care pathway for the last days of life in nursing homes.

AIM: this paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes. METHODS: an action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway. FINDINGS: six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional 'rehabilitative' culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathway for the last days of life less straightforward than in other settings. CONCLUSION: it cannot be presumed that the implementation of a care pathway for the last days of life in nursing homes is straightforward. This study suggests that an action research framework was extremely useful in highlighting and overcoming some obstacles when developing evidence-based practice. Action at both local and public policy level is required to fully address barriers that prevent quality end-of-life care in nursing homes.

Aged↗

PubMed1996

Implementation of computerized social work data base/assessments.

The Department of Veterans Affairs, Social Work Service has designed, developed and implemented the Social Work Information Management System (SWIMS) which provides for the collection and reporting of both administrative and clinical information. This paper describes the implementation of one component of SWIMS, the automated Social Work Data Base/Assessment. The discussion details the implementation process and discusses issues encountered in the implementation of a computerized documentation system.

Computer User Training↗

PubMed2000

Provider education to promote implementation of clinical practice guidelines.

STUDY OBJECTIVES: Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS: Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS: Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS: To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.

Asthma↗

PubMed2004

The implementation of acute versus chronic animal models for treatment discovery in Parkinson's disease.

Animal models for neuropsychiatric disorders are implemented for the purpose of investigating a single or multiple aspects of a specific disease entity. In Parkinson's disease (PD) several models have been utilised to study the biochemical and behavioural consequences of dopamine (DA) neurone degeneration with the intent of further understanding the aetiology of this disease and improving its treatment. While the bilateral 6-hydroxydopamine (6-OHDA) model has been used to produce a broad spectrum of neurochemical and behavioural deficits characterising DA degeneration in humans, this model is traumatic, labour intensive and is associated with high mortality due to the acute effects of the neurotoxin. Consequently, the unilateral 6-OHDA model was developed and implemented. In this model damage to the ascending DA system is produced on one side of the brain thereby inducing postural rotation. This movement is exaggerated by activating the remaining DA systems with apomorphine or amphetamine thereby making it more quantifiable. In view of the less traumatic effects on homeostasis and relative ease with which this model can be implemented it has been used routinely for the purpose of screening potential anti-Parkinsonian drugs for clinical use. However, like any model, the use of the unilateral rotation model has its limitations. It is proposed that the process of exaggerating DA function using this paradigm limits the discovery of potential anti-PD drugs to those which are effective in counteracting an exaggerated DA response. This factor may account for the high incidence of unwanted side effects including involuntary movement, tardive dyskinaesia (TD) and psychosis which are commonly observed in DA replacement therapy. Secondly, this approach limits potential drug candidates to those acting exclusively on brain DA systems. This too is a problem in the sense that PD is known to be a disease involving numerous systems in the human brain and potential therapies acting via other neurochemical systems are being excluded when this model is used exclusively. The object of the present paper is to report the discovery of a non-DA drug possessing potent anti-Parkinsonian qualities which were revealed using the bilateral 6-OHDA model of PD as a screening tool. When the same drug was retested in the traditional unilateral screening model no effect was observed, while more advanced models confirmed its efficacy. These results illustrate that the implementation of appropriate models for revealing new treatment strategies for PD should be broadly based so that single treatment entities are not exclusively pursued for diseases whose aetiologies are multifaceted. Premature extrapolation of findings from a single, early stage model to its clinical counterpart can be detrimental to advancing new treatment strategies, induce false hope, and increase morbidity in PD patients.

5-Methoxytryptamine↗

PubMed2006

Patterns of HIV prevalence and HIV risk behaviors among injection drug users prior to and 24 months following implementation of cross-border HIV prevention interventions in northern Vietnam and southern China.

In 2002, we implemented a 4-year HIV prevention intervention for injection drug users (IDUs) in Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China, a cross-border region seriously affected by inter-twined epidemics of heroin injection and HIV infection. The interventions involve peer education on HIV risk reduction and provision of new needles/syringes through direct distribution and pharmacy vouchers. We consider this to be a structural intervention in which risk reduction information and sterile injection equipment are diffused through the IDU populations and not limited to those who actually interact with peer educators. The evaluation of structural interventions poses complex methodological challenges. The evaluation of our interventions relies primarily on cross-sectional surveys (interviews and HIV testing) of samples of IDUs selected using a combination of targeted cluster and snowball methods. We consider this to be an appropriate, albeit imperfect, design given the study context. This paper presents analyses of data from the IDU surveys conducted just prior to implementation of the interventions and 24 months thereafter. The cross-border interventions have reached large proportions of the IDUs in the project sites, drug-related HIV risk behaviors have declined in frequency, and HIV prevalence among IDUs has been stable in China and declined in Vietnam over the 24 months since the interventions were implemented. Attribution of these positive trends to the interventions must be qualified in light of possible sampling biases and the absence of control groups. However, we believe that the structural interventions implemented by the cross-border project have played a role in stabilizing HIV prevalence among IDUs two years after they were initiated. Evidence of further diffusion of the interventions among IDUs and continued stability or decline of HIV prevalence would strengthen this case.

Adult↗

PubMed2006

Implementation and case-study results of potentially better practices for staffing in neonatal intensive care units.

OBJECTIVE: Five NICUs that participate in the Vermont Oxford Network Quality Improvement Collaborative have implemented several potentially better practices in an attempt to decrease nurse turnover by 50%. These potentially better practices focus on orientation, rewards and recognition, healthy work environment, nurse-physician collaboration, and nursing autonomy. METHODS: Each unit implemented some or all of the potentially better practices. An Excel spreadsheet tool for tracking turnover rates was developed and used to measure the impact of the potentially better practices on retention. Rates were measured quarterly. RESULTS: After implementation of the potentially better practices, turnover rates fell at all of the NICUs ranging from 13% to 64%. CONCLUSIONS: Nurse retention is multifactorial. Implementation of the potentially better practices had a positive influence on nurse satisfaction but a varied impact on nurse retention. The impact of larger issues such as pay and staffing levels is significant and may not be influenced at the unit level.

Focus Groups↗

PubMedDate not supplied

[The nurse's participation in implementing the Family Health Program (PSF0 in Belo Horizonte].

This study analyzes the nurse's participation in implementing the Family Health Program (PSF) in Belo Horizonte and aims at understanding their inclusion and expectations as an agent in the organization of health services and in overcoming problems found in the implementation of the program in a large city. A qualitative approach is used based on dialectic historic materialism. Eleven nurses participating in the PSF were the subjects of the research. Data was collected by means of a semi-structured interview and submitted to a discourse analysis treatment. The results demonstrate that the nurse has been involved with family health and playing a significant role ever since the implementation of the Community Health Agents Program (PACS) and that their inclusion in the PSF is favored both by their generalist background and their experience in planning, executing and evaluating health actions. Factors related to the nurse's work conditions, such as inadequacy of the environment, differentiated salary and treatment in relation to the doctor in team activities and the overload of tasks and responsibilities stand out as difficulty factors in implementing the PSF in Belo Horizonte.

Brazil↗

PubMedDate not supplied

[Clarifying the implementation of nursing care systematization].

This study has reviewed the national literature regarding nursing assistance systematization (NAS), with the aim of identifying the difficulties implementing this practice and the factors that interfere with and harm its implementation. The MEDLINE, LILACS, and BDENF databases have been utilized and six studies published in nursing periodicals in the last five years have been surveyed. The results indicate several difficulties implementing the NAS and several factors that interfere negatively with its implementation. Considering the importance of this assistance methodology for valuing professional nursing, it is necessary to reflect on/discuss its practical difficulties so that we can overcome them, making it a pleasurable activity capable of providing nurses with autonomy and providing patients with quality assistance.

Humans↗

PubMed2006

[Implementation of the Family Health Program and socio-spatial exclusion in the city of São Paulo, Brazil].

The present article analyzes the implementation of the Family Health Program (FHP) in São Paulo, Brazil, taking as its reference the occupation of the city's space, characterized by strong socio-spatial segregation. The population coverage and consolidation achieved by the FHP and the partner institutions' legal and institutional formats were identified in 96 Administrative Districts (AD). The study then proceeded to stratify these ADs beginning with their position in a ranked social exclusion map. ADs were classified in five groups. Based on these results, a typology was produced in the FHP implementation in this capital city of the State of São Paulo. Clearly distinct patterns were identified when the ADs were ranked for exclusion/inclusion. FHP implementation was effective within the peripheral ADs, especially those in Group 1, indicating pressure for the Municipal Health Secretariat to comply with its discourse, which had assumed the FHP as a health care model to be implemented throughout the city, at least reaching the entire low-income population.

Brazil↗

PubMed2007

Implementing the Medicare drug benefit in a diverse inner-city community.

PURPOSE: An integrated effort to maintain continued access to pharmacy services and prescribed medications for patients in an inner-city community before and during the implementation of the Medicare prescription drug benefit is described. SUMMARY: An academic medical center and college of pharmacy in a culturally diverse, inner-city Chicago community created a strategy to provide uninterrupted pharmacy services to all of their Medicare Part D eligible patients, particularly those dual eligible for Medicaid and Medicare, during the transition from Medicaid to Medicare Part D, effective January 1, 2006. The percentage of dual-eligible patients in the Medicare Part D eligible population at the institution was more than twice the national average. A task force was created to prepare for the onset of Medicare Part D. The task force had goals in three areas: education, outreach, and operations; it was also responsible for the development of a contingency plan for any problems that could happen after January 1. A Medicare drug benefit consult service was formed to ensure that Medicare eligible patients understood the Medicare drug benefit and received customized assistance. Although problems were encountered, the investment in the preparation and implementation of the Medicare drug benefit, especially the consult service, resulted in a positive return on the institution's investment. Suggestions for other institutions facing the challenge of the implementation of the Medicare drug benefit are provided. CONCLUSION: Implementing a federal-level program among a diverse subset of patients is challenging and requires concerted efforts from health care providers and support from the institution. The Medicare drug benefit task force at the institution assumed responsibility for all pharmacy activities related to Medicare Part D and achieved its goals in education, outreach, and operations. This resulted in continued access to pharmacy services and prescribed medications for patients.

Adolescent↗

PubMed2006

Implementation impediments to institutionalising the practice of sustainable urban water management.

It is now well accepted that there are significant challenges to realising the widespread and self-sustaining implementation of sustainable urban water management. It is argued that these challenges are entrenched within the broader socio-political framework, yet often unsuccessfully addressed within the more narrow scope of improving technical knowledge and design capacity. This hypothesis is investigated through a comparative analysis of three independent research projects investigating different dimensions of the water cycle, including stormwater management in Australia and sanitary waste management and implementation of innovative technologies in the U.K. The analysis reveals significant and common socio-political impediments to improved practice. It was evident that the administrative regime, including implementing professionals and institutions, appears to be largely driven by an implicit expectation that there is a technical solution to solve water management issues. This is in contrast to addressing the issues through broader strategies such as political leadership, institutional reform and social change. It is recognised that this technocratic culture is inadvertently underpinned by the need to demonstrate implementation success within short-term political cycles that conflict with both urban renewal and ecological cycles. Addressing this dilemma demands dedicated socio-technical research programs to enable the much needed shift towards a more sustainable regime.

Cities↗

PubMed2002

Implementation and integration of regional health care data networks in the Hellenic National Health Service.

BACKGROUND: Modern health care is provided with close cooperation among many different institutions and professionals, using their specialized expertise in a common effort to deliver best-quality and, at the same time, cost-effective services. Within this context of the growing need for information exchange, the demand for realization of data networks interconnecting various health care institutions at a regional level, as well as a national level, has become a practical necessity. OBJECTIVES: To present the technical solution that is under consideration for implementing and interconnecting regional health care data networks in the Hellenic National Health System. METHODS: The most critical requirements for deploying such a regional health care data network were identified as: fast implementation, security, quality of service, availability, performance, and technical support. RESULTS: The solution proposed is the use of proper virtual private network technologies for implementing functionally-interconnected regional health care data networks. CONCLUSIONS: The regional health care data network is considered to be a critical infrastructure for further development and penetration of information and communication technologies in the Hellenic National Health System. Therefore, a technical approach was planned, in order to have a fast cost-effective implementation, conforming to certain specifications.

Computer Communication Networks↗

PubMed2005

Postoperative parathyroid hormone levels in conjunction with corrected calcium values as a predictor of post-thyroidectomy hypocalcemia: review of outcomes 1 year after the implementation of a new protocol.

OBJECTIVES: To determine the effectiveness of post-thyroidectomy parathyroid hormone (PTH) levels in conjunction with corrected calcium values as predictors of patients at risk of developing hypocalcemia. METHODS: This is a follow-up study reviewing the results of a newly implemented post-thyroidectomy algorithm. The changes in management from the previous protocol involve decision making based on the 12-hour corrected calcium and PTH levels, as well as the 1-hour PTH value. The study involved 120 patients separated into two groups: 60 prior to implementation of the protocol and 60 following the implementation of the protocol. Patients having completion thyroidectomy, neck dissections, or parathyroidectomy were excluded. RESULTS: Since the implementation of the new protocol, there has been a reduction in the rate of transient hypocalcemia (25% to 12%; p = .059), fewer blood tests (23 to 15 per patient), and earlier patient discharges. CONCLUSIONS: The new algorithm is effective in detecting patients who are not at risk of developing hypocalcemia at 12 hours. This has led to significant cost savings at our institution. Moreover, calcium supplementation based on the 1-hour PTH level has coincided with a reduction in cases of transient hypocalcemia.

Adult↗

PubMed1995

Implementation of treatment protocols in the Diabetes Control and Complications Trial.

OBJECTIVE: To describe the methods used to implement intensive and conventional therapies in the Diabetes Control and Complications Trial (DCCT) and the metabolic results that occurred with the different treatment regimens. RESEARCH DESIGN AND METHODS: The DCCT was a controlled clinical trial that demonstrated the beneficial effect of intensive therapy on the long-term complications of insulin-dependent diabetes mellitus (IDDM). A total of 1,441 volunteers with IDDM, aged 13-39, from 29 centers in the U.S. and Canada, were randomly assigned to conventional or intensive diabetes therapy. Intensive therapy, which used multiple daily injections (MDI) of insulin ( > or = 3 injections/day) or continuous subcutaneous insulin infusion (CSII), was implemented by a team that included diabetes nurses, dietitians, behavioral experts, and diabetologists. Volunteers in the intensive treatment group could use MDI or CSII, based on patient and clinic preference, and could switch between therapies over the course of the study. The volunteers were followed for a mean of 6.5 years (range 3-9 years). RESULTS: A detailed analysis of implementation of the two treatments indicates that intensive and conventional treatment subjects adhered to their respective insulin injection regimens > 97% of the time. Adherence to other elements of intensive treatment was similarly high and resulted in median HbA1c values between 6.7 and 7.2, compared with 8.7-9.2 with conventional therapy, over the course of the study. Severe hypoglycemia occurred three times more often in intensively treated subjects. Although subjects on intensive treatment were not randomly assigned to MDI or CSII, we compared those subjects who used either of these methods for > or = 90% of the study time. CSII-treated patients maintained a mean HbA1c of 6.8 vs. 7.0 in MDI-treated subjects during the trial (P < 0.05). The frequency of hypoglycemia with coma and seizure and diabetic ketoacidosis was modestly higher with CSII than with MDI. CONCLUSIONS: Intensive therapy was implemented successfully in the DCCT. The detailed description herein will serve to facilitate translation of the DCCT results to the clinical setting.

Adolescent↗

PubMedDate not supplied

Methods of implementation of the MUMPS global data-base.

Recent standardization of the MUMPS language (ANSI X11.1-1977) has resulted in increased investigations into its efficient implementation. Of particular concern is the method of implementation of the MUMPS hierarchical data file, or global. Two implementation techniques have found substantial support: a traditional technique utilizing linked physical blocks, and a more recent, self-indexing method based on the theory of balanced trees. Comparison of these methods shows that the balanced-tree implementation offers significant advantages in most MUMPS environments.

Computers↗

PubMed2006

The role of organizational infrastructure in implementation of hospitals' quality improvement.

Quality improvement (QI) is an organized approach to planning and implementing continuous improvement in performance. Although QI holds promise for improving quality of care and patient safety, hospitals that adopt QI often struggle with its implementation. This article examines the role of organizational infrastructure in implementation of quality improvement practices and structures in hospitals. The authors focus specifically on four elements of hospital support and infrastructure for QI-integrated data systems, financial support for QI, clinical integration, and information system capability. These macrolevel factors provide consistent, ongoing support for the QI efforts of clinical teams engaging in direct patient care, thus promoting institutionalization of QI. Results from the multivariate analysis of 1997 survey data on 2350 hospitals provide strong support for the hypotheses. Results signal that organizations intent upon improving quality must attend to the context in which QI efforts are practiced, and that such efforts are unlikely to be effective unless appropriate support systems are in place to ensure full implementation.

Data Collection↗

PubMed2006

Implementation of the Texas Medication Algorithm Project patient and family education program.

OBJECTIVE: This article describes the implementation and utilization of the patient and family education program (PFEP) component of the Texas Medication Algorithm Project (TMAP). The extent of participation, types of psychoeducation received, and predictors of receiving at least a minimum level of education are presented. METHOD: TMAP included medication guidelines, a dedicated clinical coordinator, standardized assessments of symptoms and side effects, uniform documentation, and a PFEP. The PFEP includes phased, multimodal, disorder-specific educational materials for patients and families. Participants were adult outpatients of 1 of 7 community mental health centers in Texas that were implementing the TMAP disease management package. Patients had DSM-IV clinical diagnoses of major depressive disorder, with or without psychotic features; bipolar I disorder or schizoaffective disorder, bipolar type; or schizophrenia or schizoaffective disorder. Assessments were administered by independent research coordinators. Study data were collected between March 1998 and March 2000, and patients participated for at least 1 year. RESULTS: Of the 487 participants, nearly all (95.1%) had at least 1 educational encounter, but only 53.6% of participants met criteria for "minimum exposure" to individual education interventions. Furthermore, only 31.0% participated in group education, and 42.5% had a family member involved in at least 1 encounter. Participants with schizophrenia were less involved in the PFEP across multiple indicators of utilization. Diagnosis, intensity of symptoms, age, and receipt of public assistance were related to the likelihood of exposure to minimum levels of individual education. CONCLUSION: Despite adequate resources and infrastructure to provide PFEP, utilization was less than anticipated. Although implementation guidelines were uniform across diagnoses, participants with schizophrenia experienced less exposure to psychoeducation. Recommendations for improving program implementation and modification of materials are discussed.

Adult↗