Abstract
BackgroundClinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.MethodsThe TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated.ResultsFollowing intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) p < .05, to 8.14 (3.06 to21.67) p < .001] compared to the control hospital, which remained unchanged [risk ratio (CI) = .77 (.47-1.26) p = .296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years.ConclusionThe TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0648-4) contains supplementary material, which is available to authorized users.
Highlights
Clinical guidelines are an integral part of healthcare
The use of pH as a first line method at baseline was lower in the intervention hospitals (H1 = 18.4%, H2 = 11.6%, H3 = 13.6%) compared to the control hospital (H4 = 45.3%), whilst the use of X-rays was higher in the intervention hospitals (H1 = 49%, H2 = 76.7%, H3 = 40.9%) compared to the control hospital (H4 = 24.5%)
Using the Theoretical Domains Framework Implementation (TDFI) approach across three hospitals, we have demonstrated that co-designing interventions using evidence based strategies to address key barriers can significantly increase the uptake of national recommendations of NG tube positioning and significantly reduce the use of less safe behaviours
Summary
Clinical guidelines are an integral part of healthcare. Guidelines often summarise complex and rapidly changing research evidence with the aim of speeding up the translation of evidence into routine clinical practice and reducing unwarranted variations in the quality of care. A range of methods have been developed to implement guidelines in routine practice – but, evaluations of these approaches have demonstrated variable effects [2,3]. This may be explained by the difficulties associated with changing behaviour, especially within complex social and environmental systems that demonstrate local variations [4]. Interventions to enhance the quality and safety of health care may be more effective when developed by those with local ‘expertise’ and tacit knowledge [5,6,7], and underpinned by evidence from behaviour change and implementation science literature [8,9,10,11]
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