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At least 1,099 records · Page 61Linked to original sources

PubMed2004

Results of a randomized controlled trial of intervention to implement smoking guidelines in Veterans Affairs medical centers: increased use of medications without cessation benefit.

BACKGROUND: The AHRQ Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends screening and treatment of all tobacco users. Effective methods to implement recommendations are needed because simple guideline dissemination does not necessarily result in changes in practice. OBJECTIVES: The Guideline Implementation for Tobacco (GIFT) study tested an organizational intervention to improve Guideline implementation. RESEARCH DESIGN: GIFT randomized 20 Veterans Affairs medical centers to intervention or control conditions. We trained prime movers at each site to improve identification of smoking status, promote primary care interventions and increase availability of smoking cessation medications. Sites and patients were evaluated before and after intervention. SUBJECTS: GIFT included 20 Veterans Affairs medical centers and 5678 subjects. MEASURES: Data regarding smoking status, delivery of treatment, medication use, and smoking cessation were collected from participant surveys, medical record review, survey of site leaders, and Pharmacy Benefits Management. RESULTS: The intervention did not increase participant report of being asked about smoking status or receipt of counseling. It did increase the rate of identification of smoking status in the medical record (P = 0.0001) but did not increase the rate of counseling to stop smoking. Site level data showed no increase in the number of patients receiving smoking cessation medications or dollars spent on medications. Individual smoker data showed a significant increase in the use of medications for smoking cessation in intervention sites (odds ratio = 6.89, P < 0.0001); however, only a small minority of smokers received medication even after the intervention. There was no difference in smoking cessation rates between participants at the intervention and treatment sites. CONCLUSIONS: We conclude that improvements in smoking cessation rates are likely to require more intensive intervention in this population.

Cohort Studies↗

PubMedDate not supplied

Screening for abuse during pregnancy: implementing a multisite program.

Screening for abuse at every healthcare visit is a standard of practice promulgated by many healthcare professional organizations. The need for such screening is underscored by reports of homicide as a leading cause of maternal mortality during pregnancy and the first year of the baby's life in Massachusetts and Maryland, and by the calculation of the costs of intimate partner violence in the United States. This article discusses how we addressed problems that arose in implementing screening for abuse in 13 different sites as a part of a clinical nursing research project. Engaging in clinical nursing research necessitates close relationships with clinical agencies and their staff members. This often means establishing and maintaining relationships with all nurses caring for patients in each clinical unit serving as a study site. For research on abuse during pregnancy, our study team members were engaged in interactions with prenatal care providers at 13 different study sites. Central to the study was implementing use of a standardized abuse screening tool, the Abuse Assessment Screen, at each study site. This article also describes the lessons we learned in attempting to implement such a large scale change in clinical practice.

Adult↗

PubMedDate not supplied

Using diffusion of innovation concepts to enhance implementation of an electronic health record to support evidence-based practice.

The article identifies the explosion of clinical data that are available and how difficult it is for clinicians to find answers to clinical questions. Electronic healthcare records (EHRs) are increasingly used to assist clinicians in this process; however, resistance to the implementation of technology-assisted care is not uncommon. The article reviews the diffusion of innovation research and provides the nurse manager with suggestions for applying these concepts to enhance the implementation of an EHR that can support evidence-based practice. Five characteristics of innovations, as perceived by individuals, are discussed as they help explain different rates of adoption. The innovation-decision process is studied as it relates to EHR implementations.

Attitude of Health Personnel↗

PubMed1994

Implementation and impact of the Patient Self-Determination Act.

The Patient Self-Determination Act became effective in December 1991 and mandates that patients be given information about legal rights regarding living wills and durable powers of attorney for health care. We investigated the impact this law has had on hospitals, medical personnel, and patients. We conducted a survey of all hospitals in the state of Georgia, collecting data regarding implementation and knowledge of the law, as well as effects of the law and beliefs about it. The data indicated that hospitals relied primarily on the Georgia Hospital Association for implementation policy, that "minimalist" implementation of the law occurs in most hospitals, and that the biggest perceived problem with the law was the inappropriateness of presenting this information at hospital admission and problems patients had in comprehending the materials presented. Despite these concerns, most respondents did not want the law repealed.

Attitude of Health Personnel↗

PubMed1995

Reducing smoking at the workplace: implementing a smoking ban and hypnotherapy.

Smoking cessation programs may be an important component in the implementation of worksite smoking policies. This study examines the impact of a smoke-free policy and the effectiveness of an accompanying hypnotherapy smoking cessation program. Participants in the 90-minute smoking cessation seminar were surveyed 12 months after the program was implemented (n = 2642; response rate = 76%). Seventy-one percent of the smokers participated in the hypnotherapy program. Fifteen percent of survey respondents quit and remained continuously abstinent. A survey to assess attitudes toward the policy was conducted 1 year after policy implementation (n = 1256; response rate = 64%). Satisfaction was especially high among those reporting high compliance with the policy. These results suggest that hypnotherapy may be an attractive alternative smoking cessation method, particularly when used in conjunction with a smoke-free worksite policy that offers added incentive for smokers to think about quitting.

Adult↗

PubMed1996

Implementation of the Agency for Health Care Policy and Research Pain Guidelines.

Implementation of clinical practice guidelines in a large setting is a complex process. This article describes the many issues encountered in trying to implement Agency for Health Care Policy and Research acute pain and cancer pain guidelines in an academic medical center. Issues addressed include the membership of the task forces involved, incorporation of the guidelines into the institution-specific standards of care, selection and implementation of self-reporting tools for assessment of pain throughout the institution, issues involved in standardizing documentation of pain throughout the institution, measurement of the current status of pain control and integration into the existing quality assessment and improvement program, various analgesic interventions addressed throughout the hospital, educational strategies used and planned, and how multidisciplinary involvement was obtained.

Humans↗

PubMed2001

Success indicators and barriers to acute nurse practitioner role implementation in four Ontario hospitals.

Changes in healthcare environmental factors resulted in the introduction of the acute care nurse practitioner (ACNP) role in Ontario. The purpose of the study was to identify success indicators, barriers, and recommendations for role implementation to assist healthcare providers to develop strategies for integrating ACNPs into teams. Acute care nurse practitioners (n = 14), physicians (n = 14), administrators (n = 12), and staff nurses (n = 48) from four tertiary care hospitals completed a researcher-developed, self-administered questionnaire with fixed and open-ended questions. Specialty practice areas (cardiac/critical care, geriatrics, and nephrology) were matched within the four sites. Acute care nurse practitioners (n = 14), physicians (n = 12), administrators (n = 8), and staff nurses (n = 34) responded. The major indicator by all groups for successful role implementation was level of preparation. Barriers included lack of mentorship and knowledge of the role, and perceived lack of support from administration and physicians. Themes reflecting impact on patient care were improved communication and attention to patient care issues. Respondents accepted the role, concluding that enhanced continuity of care was a result. Role clarity before and during implementation would assist team members in understanding the purpose and value of the role, thus easing the integration of the ACNP into the healthcare team.

Health Facility Environment↗

PubMedDate not supplied

Evidenced-based practice: priorities and implementation strategies.

Evidenced-based practice (EBP) should be a driving force behind establishing optimal clinical practices. Recently, clinicians and hospitals have started efforts to introduce key EBP. These efforts hold the potential to improve patient outcomes and reduce costs. However, many practices need updating with EBP. Which ones should be chosen? While practices often vary in terms of importance for each hospital, some changes in practice are likely to have a better return on the investment (ROI). Two key areas affecting most hospitals are practices associated with high costs and increased mortality. In critical care areas, these two key areas often involve addressing outlier management and severe sepsis. In addition, the recognition of the need for the change is only one step in ensuring EBP. To ensure EBP is implemented, clinical leaders who will ensure that the new practice standards are being utilized are necessary. Fortunately, many hospitals have strong leaders. The advanced practice nurse (APN) is one such leader. The APN is often in a unique position to help recognize, prioritize, and implement EBP into the hospitals culture. This article illustrates steps in making EBP a reality by highlighting the management of outliers and severe sepsis and the implementation strategies for these conditions.

Bias↗

PubMed1997

A cost evaluation of implementing a quality-oriented, regional perinatal data system.

We evaluated the cost impact of implementing a perinatal data system (PDS) on birth certificate (BC) processing and perinatal quality improvement (QI) reporting. Relevant staff in all birthing hospitals in the 15-county Central New York region (N = 23) were interviewed at baseline prior to implementation of the PDS and one year after implementation of the PDS to ascertain the time and costs of BC processing and of QI report generation. The average time and cost to collect and complete BCs did not change significantly from baseline to year 1. The time and costs to complete QI reports decreased significantly by 70 percent during this same period. Hospitals fully using the PDS for QI reporting purposes took, on average, six percent of the time it took other hospitals to generate comparable QI reports. The PDS significantly reduced the time and cost of generating perinatal reports from a consolidated database over what hospitals had done previously. Given the richness of the reports and the efficiency with which they are produced, hospitals are encouraged to adopt electronic means of BC processing and accessing these data for QI reporting purposes.

Automation↗

PubMedDate not supplied

Local public health performance measurement: implementation strategies and lessons learned from aligning program evaluation indicators with the 10 essential public health services.

This case study summarizes the development and implementation of the evaluation framework, preliminary data results, and lessons learned for overcoming barriers and challenges. The framework development was based on best practices in evaluation and the Public Health Essential Services. Results were as follows: (1) implemented a department-wide framework for program evaluation; (2) developed and implemented 34 program evaluation plans; (3) collected data on 52 indicators across 492 measurable objectives; and (4) identified challenges and recommendations to improve evaluation processes. Although the importance of program evaluation is recognized in public health, program evaluation models do not take into account the variety of goals inherent in the diversity of public health programming. The case study presented provides guidance and lessons learned for the evaluation of public health practice in local governments.

Benchmarking↗

PubMedDate not supplied

Implementation and results of a test dose program with taxanes.

PURPOSE: A pilot taxane test-dose policy was developed and implemented to determine whether the severity of patient hypersensitivity reaction and drug waste would be reduced. PATIENTS AND METHODS: Data from 206 eligible cancer patients undergoing first-dose taxane chemotherapy were analyzed. The severity of hypersensitivity reactions before and after the implementation of taxane test dose was graded (scale 1-4) and analyzed for statistical differences between groups. Average drug wastage was calculated before and after program initiation. RESULTS: Twenty-two of 206 patients (10.7%) experienced a hypersensitivity reaction. The mean hypersensitivity reaction severity for reacting patients who did not receive a test dose (N = 12) was 3.3, and for those who were given a test dose (N = 10), it was 1.5. Only one of five patients who experienced a hypersensitivity reaction that required hospitalization was from the test-dose group. The value of drug alone wasted before test-dose utilization was about $1794 per reacting patient, and the use of taxane test doses saved approximately $1784 per reacting individual. This represented more than a $178 savings for every patient receiving a taxane for the first time. These figures do not include resuscitation, hospital, and other subsequent other costs associated with morbidity. CONCLUSIONS: Implementation of a taxane test-dose policy significantly reduced hypersensitivity reaction severity, drug wastage, and hospitalizations.

Adult↗

PubMed2005

Implementation of a quality systems approach for laboratory practice in resource-constrained countries.

Under the direction of the US Global AIDS Coordinator's Office, Department of Health and Human Services, the CDC Global AIDS programme helps resource-constrained countries to address the global HIV/AIDS pandemic. Activities include laboratory capacity and laboratory infrastructure development in 25 resource-constrained countries. Medical practitioners and public health programme leaders in industrialized countries rely on the use of quality laboratory data for evidence-based medical decision-making to determine policy for the implementation of disease control measures, to monitor disease to determine the impact of control programmes, and to support surveillance activities. In these countries, laboratory data to support decision-making processes have a level of quality attributable to laws, regulations and guidelines developed over many years. However, resource-constrained countries have not had similar experiences. Few countries have developed laws, regulations or guidelines, nor is there a data-use culture (e.g. evidence-based medicine) for those in the decision-making environment in resource-constrained countries. The strengthening of laboratory capability and capacity in resource-constrained countries is an important goal to improve accurate and reliable data for the diagnosis, treatment and monitoring of disease.A process for the implementation of a quality systems approach for a laboratory is presented: (i) acknowledgement of the need to improve the laboratory programme in the country at the Ministry of Health and at all decision-making levels within the provinces/states of the country; (ii) assessment of capabilities, capacities, infrastructure, and training needs; (iii) implementation of a national meeting of laboratorians; (iv) designation of a national Quality Assurance Office and leadership within that office; (v) the development and provision of technical training.

Developing Countries↗

PubMed2006

Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology.

BACKGROUND: Cardiovascular disease mortality remains high in Europe and many patients have elevated risk factors, despite evidence-based targets and treatment guidelines. This survey examined barriers to implementing cardiovascular risk reduction guidelines. DESIGN: We conducted a semi-structured market research survey of physicians. METHODS: The survey was conducted in six European countries among cardiologists and primary care physicians. In total, 67 questions were used: 35 had multiple choice answers (prompted) and 32 allowed any answer (unprompted). Respondents were working full-time in patient care (>or=3 years experience) and were in a position to initiate cardiovascular drug treatment. RESULTS: Of the 220 respondents (155 primary care physicians, 65 cardiologists), most (85%) based assessment of cardiovascular risk on all risk factors, reflecting a global approach to risk, rather than considering risk factors individually. A majority (62%) used subjective assessments for establishing global risk rather than guidelines or risk calculators. The most common unprompted barrier to guideline implementation was patient compliance (36%) and a lack of time (23%), and when prompted, the most important was government health policy (40%). The most common unprompted suggestion for improving implementation were financial opportunities (24%) and clear and easy to use guidelines (23%), while when prompted the most important change required was the development of simpler guidelines (46%). CONCLUSIONS: Although a majority of physicians are aware of the need to look at a combination of cardiovascular disease risk factors, less than half use guidelines or risk calculators to determine total risk. It is recommended that guidelines need to be simpler and easier to use and supplemented with (patient friendly) risk calculators.

Cardiovascular Diseases↗

PubMed2005

Implementation of cascade testing for the detection of familial hypercholesterolaemia.

PURPOSE OF REVIEW: Cascade testing is an important method for identifying individuals at risk of a genetic condition. Recent advances in its application to familial hypercholesterolaemia are reviewed to identify potential problems impeding its application and the extent to which current data address these concerns. RECENT FINDINGS: Different paradigms for cascade testing are being applied in national programmes. Current data demonstrates cost-effectiveness, and an increased uptake of preventive measures. The relationship between molecular and clinical diagnostic methods is discussed. Psychological impacts of a diagnosis of familial hypercholesterolaemia are in line with the risks associated with the disorder. The efficacy of statins in improving vascular function of children with familial hypercholesterolaemia has been demonstrated, but extensive safety data are lacking. Ethical arguments support that it is equally acceptable for relatives of familial hypercholesterolaemia patients to be contacted by healthcare workers as by family members, but the former is likely to be more efficient. Concerns about increased life insurance premiums are valid but insurance companies are assessing risk realistically, so this should not be a barrier to cascade testing. SUMMARY: Current data support the implementation of cascade testing for familial hypercholesterolaemia as being feasible and cost-effective, but national implementation is limited to a small number of countries. Funding and the infrastructure to support it may be the major stumbling blocks in implementing this technique in many countries. Concerns about the ethics of carrying out cascade testing, and the potential psychological damage of DNA testing, appear to have been largely addressed for familial hypercholesterolaemia.

Genetic Testing↗

PubMed2004

Core competencies in neurology resident education: a review and tips for implementation.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Core Competency project for graduate medical education was developed in the late 1990s and is now being implemented in residency programs across all specialties. Program directors and residents in neurology are seeking national guidance in how to adjust educational curricula and establish new evaluation tools that meet ACGME standards. REVIEW SUMMARY: This review summarizes the competency movement and outlines specific guidelines and resources for neurology programs including national efforts underway through the American Academy of Neurology (AAN), Neurology Residency Review Committee, and other subspecialty organizations. Resident and program director concerns for implementation are highlighted, with a focus on use of national resources and established evaluation tools. CONCLUSIONS: All neurology programs must comply with new requirements generated by the competencies that will require significant time and energy for program directors. An effective approach to implementation involves careful review of existing evaluation tools established by other subspecialties and expansion of reliable tools used already in place in most programs such as the mock oral board and RITE In-Training Examination. The individual program director is encouraged to monitor resources nationally through the AAN Program Director's Consortium and locally through institutional projects which can incorporate neurology residents.

Accreditation↗

PubMed2004

Complying with the Occupational Safety and Health Administration's Bloodborne Pathogens Standard: implementing needleless systems and intravenous safety devices.

Preventing the transmission of bloodborne pathogens to healthcare workers has been a mission and a challenge of the healthcare industry for over 20 years. The development of the Occupational Safety and Health Administration Bloodborne Pathogens Standard in 1991 and the passing of the Needlestick Safety Act in 2000 mandated hospitals to develop an Exposure Control Plan to protect workers from these pathogens. Children's Hospital Boston began implementation of a needleless system in 1993. Employees readily accepted these systems into practice, because they were convenient and easy to use. A marked decrease in exposures to bloodborne pathogens naturally followed, which is consistent with the national data. The transition to intravenous (i.v.) safety devices at Children's Hospital began in 2000 and proved to be more of a challenge. First, the clinicians must choose a safety product, which requires developing and implementing a trial plan with potential catheters. This selection process is especially difficult in pediatrics where successful placement of the smallest-gauge catheter, no. 24, is imperative. After choosing an i.v. safety product, successful transition is dependent upon the thoroughness of i.v. safety device training and a commitment by the clinicians to the use of these products. Although the number of needlestick injuries and subsequent transmission of bloodborne pathogens have been further reduced with the use of i.v. safety devices, needlestick injuries still occur. This results from a lack of familiarity with the engineering of the device and therefore poor technique or a failure to activate the safety mechanism. Staff resistance due to loss of expertise with the new device and patient care concerns are additional barriers to the use of these new products. Addressing these obstacles and providing adequate training for all clinicians were required for successful implementation of these i.v. safety devices.

Attitude of Health Personnel↗

PubMed2006

Modified directly observed therapy to facilitate highly active antiretroviral therapy adherence in Beira, Mozambique. Development and implementation.

As resource-limited countries expand access to highly active antiretroviral therapy (HAART) treatment, innovative programs are needed to support adherence in the context of significant health system barriers. Modified directly observed therapy (mDOT) is one such strategy, but little is known about the process of designing and implementing mDOT programs for HAART in resource-limited settings. In this descriptive study, we used a mixed-methods approach to describe the process of implementing mDOT for an ongoing randomized control trial (RCT) in Beira, Mozambique. Interviews with clinic staff, mDOT peers, and participants provided information on design elements, problems with implementation, satisfaction, and benefits. Acceptability and feasibility measures were obtained from the RCT. Most (81%, N = 350) eligible persons agreed to participate, and of those randomized to mDOT (n = 174), 95% reported that their time with peers was beneficial. On average, participants kept 93% of the 30 required daily mDOT visits. Key components of the intervention's success included using peers who were well accepted by clinic staff, adequate training and retention of peers, adapting daily visit requirements to participants' work schedules and physical conditions, and reimbursing costs of transportation. This study identified aspects of mDOT that are effective and can be adopted by other clinics treating HIV patients.

Adult↗

PubMed2006

Implementation of a norepinephrine-based protocol for management of septic shock: a pilot feasibility study.

BACKGROUND: The subject of the best vasopressor for hemodynamic management of septic shock (SS) is controversial. One of the difficulties in planning such studies is that physicians are reluctant to use one vasopressor exclusively, and there is considerable variation in practice. The aim of this study was to test the feasibility of implementing a single pressor-based algorithm (in this case, norepinephrine [NE]). METHODS: A NE-based algorithm was applied prospectively to 100 consecutive SS patients. A formal training program was implemented before starting the protocol and applied to 72 physicians and nurses involved in intensive care unit (ICU) patient care. Compliance, protocol violations, probable adverse effects, and outcome were evaluated on a daily basis by an independent group of fellows and a research nurse. RESULTS: In 100 patients, there were 7,139 hours of algorithm use. Only 13 protocol violations were observed, mostly in the timing of inotropic drugs. Senior staff physicians or busy night shifts accounted for most of these violations. ICU mortality was 33%, which is comparable to that predicted by Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. Adverse events probably related to NE were not observed. CONCLUSIONS: The present algorithm, applied after a strict training program, obtained an overall good acceptance and compliance with very few protocol violations in more than 7,000 hours of use. Safety was demonstrated by a global mortality comparable to that predicted by severity scores and absence of specific drug-related morbidity. The implementation of a single pressor-based algorithm for SS is feasible and safe.

Adult↗