Evidence-based Prevention Practices Research Articles

Prevention of breast engorgement among postpartum women in an obstetric and gynecological hospital: a best practice implementation project

Background Breast engorgement was considered to influence confidence and continuation of breastfeeding in the first week following birth, for new mothers. Strategies for prevention of breast engorgement for postpartum women were unclear, and not in line with best practice breast engorgement guidelines. Aims The aim of this project was to integrate the available evidence of breast engorgement prevention into practice and to improve the compliance of best practice in line with audit criteria. Methods This project adopted a pre- and post-implementation audit approach. It utilised the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The project utilised six audit criteria that are considered the best practice standards. The audit took place in a 20-bed postpartum unit that involved 12 full-time qualified nurses. Results The findings of pre- and post implementation audit showed that the compliance rates for all criteria have resulted in 100% in follow up cycle. Except for the criterion of unlimited breastfeeding (which only resulted in a 3% improvement), the compliance rates have increased 30%-60% when compared to the baseline cycle. Conclusion This audit project has made a significant improvement in establishing evidence-based practices for breast engorgement prevention among postpartum women in the gynaecologic and obstetric hospital in Shanghai. Further audit will be necessary to improve clinical outcomes and nursing quality.

National Estimates of Central Line–Associated Bloodstream Infections in Critical Care Patients

OBJECTIVE. Recent studies have demonstrated that central line-associated bloodstream infections (CLABSIs) are preventable through implementation of evidence-based prevention practices. Hospitals have reported CLABSI data to the Centers for Disease Control and Prevention (CDC) since the 1970s, providing an opportunity to characterize the national impact of CLABSIs over time. Our objective was to describe changes in the annual number of CLABSIs in critical care patients in the United States. Monte Carlo simulation. Setting. U.S. acute care hospitals. Nonneonatal critical care patients. We obtained administrative data on patient-days for nearly all US hospitals and applied CLABSI rates from the National Nosocomial Infections Surveillance and the National Healthcare Safety Network systems to estimate the annual number of CLABSIs in critical care patients nationally during the period 1990-2010 and the number of CLABSIs prevented since 1990. We estimated that there were between 462,000 and 636,000 CLABSIs in nonneonatal critical care patients in the United States during 1990-2010. CLABSI rate reductions led to between 104,000 and 198,000 fewer CLABSIs than would have occurred if rates had remained unchanged since 1990. There were 15,000 hospital-onset CLABSIs in nonneonatal critical care patients in 2010; 70% occurred in medium and large teaching hospitals. Substantial progress has been made in reducing the occurrence of CLABSIs in U.S. critical care patients over the past 2 decades. The concentration of critical care CLABSIs in medium and large teaching hospitals suggests that a targeted approach may be warranted to continue achieving reductions in critical care CLABSIs nationally.

Suicidal Ideation and Behaviours after Traumatic Brain Injury: A Systematic Review

Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.

A Descriptive Evaluation of CDC's LEAN Works! Leading Employees to Activity and Nutrition—A Web-Based Employer Tool for Workplace Obesity Management

The study aim was to determine the utility of and satisfaction with a Centers for Disease Control and Prevention (CDC) Web-based employer tool, CDC's LEAN Works!, which provides evidence-based recommendations and promising practices for obesity prevention and control at worksites. This study examined employers' natural usage (i.e., without any study parameters on how, when, or how much to use the Web site and its resources) and impressions of the Web site. Employers of varying sizes, industry types, and levels of maturity in offering obesity management programs and from both private and public sectors were recruited to participate in the study. A convenience sample of 29 employers enrolled to participate. Participants were followed over a 12-month period. First impressions, bimonthly use of the Web site, and final assessments were collected using self-report surveys and individual interviews. Descriptive analyses were conducted. Almost all (96%) of participants reported a positive experience with the Web site, noting it provided a wealth of information. Most reported they planned to continue to use the Web site to develop (77%), implement (92%), and evaluate (85%) their obesity management programs. Aspects of the Web site that employers found valuable included a step-by-step implementation process, templates and toolkits, specific recommendations, and promising practices. CDC's LEAN Works! is a useful resource for employers wishing to develop and implement evidence-based workplace obesity prevention programs.

News from the CDC: collaborations to build capacity at the community level in cancer prevention and control

The Cancer Prevention and Control Research Network (CPCRN) is a national network of ten academic centers funded by the Centers for Disease Control and Prevention and the National Cancer Institute, whose mission is to accelerate the adoption of evidence-based cancer prevention and control practices in communities through increased understanding of program dissemination and implementation. CPCRN researchers collaborate to raise awareness, provide education, guidance, and technical assistance to reduce cancer incidence and mortality rates in their communities. The CPCRN capacity building at the community level involves implementing evidence-based programs, policies, and strategies recommended by the Community Preventive Services Task Force to decrease obesity, increase physical activity, promote healthier behaviors, decrease tobacco use, and improve the appropriate use of cancer screening tests. These accomplishments demonstrate how the collaboration of federal, academic, and community-based organizations can be mutually beneficial by developing partnerships, research infrastructure, and community capacity that can catalyze behavior change.

Journal Club: A venue to advance evidence-based infection prevention practice

Journal Clubs are a well-recognized strategy used by clinicians to critique and keep up to date with relevant literature. This article provides an example of an assessment of an article appearing in this issue of the American Journal of Infection Control titled, "US School/Academic Institution Disaster and Pandemic Preparedness and Seasonal Influenza Vaccination Among School Nurses."

Impact of participation in the California Healthcare-Associated Infection Prevention Initiative on adoption and implementation of evidence-based practices for patient safety and health care–associated infection rates in a cohort of acute care general hospitals

In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care-associated infection (HAI) rates. Statewide computer-assisted telephone surveys of California's general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey. Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period. Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety.

Nursing Interventions for Adult Intensive Care Patients With Risk for Corneal Injury: A Systematic Review

Sedated patients in induced comas may experience ineffective eyelid closure, presenting higher risk for corneal ulcer. The objective was to identify evidence-based practice for corneal ulcer prevention within the intensive care unit. A systematic literature review of nine articles was performed. Questions remain about which care practice is most effective, although most studies consider a humidity chamber with polyethylene film to be the best practice. A proposed NANDA-I nursing diagnosis, risk for corneal injury, reflects this human response that demands nursing assessment and intervention. This study provides evidence toward developing nursing interventions and practice guidelines for the care of these patients.

Evidence-Based Practices for Thromboembolism Prevention

In July of 2011, the American Society of Plastic Surgeons Executive Committee approved the Venous Thromboembolism Task Force Report. The report includes a summary of the scientific literature relevant to venous thromboembolism and plastic surgery along with five evidence-based recommendations. The recommendations are divided into two sections: risk stratification and prevention. The risk stratification recommendations are based on the 2005 Caprini Risk Assessment Module, which has been validated in the scientific literature as an effective tool for risk-stratifying plastic and reconstructive surgery patients based on individual risk factors for 60-day venous thromboembolism. The three prophylaxis recommendations are dependent on an individual patient's 2005 Caprini Risk Assessment Module score.

The Real World Journey of Implementing Fall Prevention Best Practices in Three Acute Care Hospitals: A Case Study

Globally, falls are the second leading cause of unintentional injury. In Canada, falls that occur in hospitals have been ranked second as an area of patient safety concern. Many Canadian hospitals seeking to achieve patient safety, accreditation and resource containment goals are implementing evidence-based practices in fall prevention. However, best practices are reported to be only variably effective in reducing hospital fall rates, indicating a potential gap in our understanding of the implementation process. This study was designed to provide insight into the real world of implementation of best practices in fall prevention in acute care Canadian hospitals. Using case study methodology, ninety-five administrative and point-of-care nurses at three hospitals participated in interviews or focus groups and provided documents and artifacts that described their implementation of a falls prevention guideline. Four recommendations with potential to guide others in fall prevention were identified: (1) the need to listen to and recognize the expertise and clinical realities of staff, (2) the importance of keeping the implementation process simple, (3) the need to recognize that what seems simple becomes complex when meeting individual patient needs, and (4) the need to view the process as one of continuous quality improvement.

Community and School Mental Health Professionals’ Knowledge and Use of Evidence Based Substance Use Prevention Programs

Youth with learning and behavioral problems are at elevated risk for substance use during adolescence. Although evidence-based substance use prevention and screening practices are described in the literature, the extent with which these are provided to these youth is unclear. Mental health professionals in schools and community mental health centers are in an ideal position to conduct substance use screening and prevention practices since they have frequent contact with this high risk group. In order to determine whether these mental health professionals were using evidence based substance use screening and prevention programs with these youth, we analyzed 345 completed surveys from mental health professionals in schools and community clinics throughout a mid-Atlantic state. Results indicated that a large portion of the respondents were unfamiliar with evidence based practices and they were infrequently used. Implications for the division of labor at schools and community mental health centers are discussed in relation to time allotment and priority for these procedures.

Reduction of surgical site infections in low transverse cesarean section at a university hospital

We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS). An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings. Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P= .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period. A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.

Preventing Students With Disabilities From Dropping Out

Schools are tasked with the challenge of not only raising graduation rates for students with and without disabilities but also preparing these students to meet college and career readiness standards. Recent studies and reviews of the literature suggest promising practices to ensure that educators meet these goals by increasing students’ engagement in school. This article provides an overview of the research on evidence-based drop-out prevention practices organized within the framework of the six recommendations provided by the Institute of Education Sciences. After an explanation of each drop-out prevention intervention component, implications for practice are highlighted, with particular emphasis on academic and behavioral practices that can be readily implemented to prevent students with and without learning and behavioral disabilities from dropping out of school.

Evidence-based practice:

Purpose: This paper describes the rationale and philosophy behind the development of a blended learning course for allied health professionals working in the field of substance use prevention and the results of an evaluation of the pilot course. The course teaches a range of information literacy skills in order to increase the participants’ knowledge of evidence-based practice and enable them to pursue an evidence-based approach in their professional work. The course Evidence-based Substance Use Prevention and Education Practice was developed and delivered by the National Documentation Centre on Drug Use (NDC), a special substance-use research library in Ireland, where the author works. The NDC is part of a drug and alcohol research unit, comprising epidemiologists, social researchers and statisticians. This unit is based in an Irish Government agency called the Health Research Board (HRB). Method: Data required for the evaluation of the pilot course were obtained from responses by participants to pre- and post-course questionnaires and from a focus group of some of those who completed the course. Findings: The course was established on the premise that the effective transfer of scientific knowledge in the field of problem drug use requires that practitioners develop information literacy skills to enable them to understand the principles of evidence-based practice. The findings of the course evaluation suggest that blended learning course in evidence-based practice is an effective way to teach these skills and promote an evidence-based approach to practice in this area. Originality: Developing information literacy skills is a key part of the inculcation of evidence-based principles in medical education and in the education of allied health professionals. The teaching of information literacy skills to students involved in health-related education has been studied extensively. The course described in this paper builds on the evidence provided by the literature and applies the principles of information literacy teaching in a setting of continuing professional development. In terms of its scope, target audience and objectives, the course is unique and the insights obtained from the delivery of the course and its evaluation form a useful and original contribution to research in this area.

228 Pain Medications Available in the Emergency Departments of a Rural State

228 Pain Medications Available in the Emergency Departments of a Rural State

The Use and Misuse of ICU Telemedicine

MORE THAN 25 YEARS HAVE PASSED SINCE THE original description of intensive care unit (ICU) telemedicine, a technological strategy to improve critical care outcomes by expanding the reach and availability of intensivist clinicians. Since then, the understanding of evidence-based practice and the role of information technology in the ICU have substantially increased. Multiple commercial applications of ICU telemedicine now exist, and telemedicine is widely touted as an all-encompassing strategy to improve ICU outcomes. Yet even after 25 years, the optimal role of telemedicine in the ICU remains uncertain. A large, multicenter study published recently showed no demonstrable clinical benefit, and a recent meta-analysis found no beneficial association between ICU telemedicine and in-hospital mortality. These results have left clinicians, hospital administrators, and policy makers wondering how to best use this technology, if at all. In this issue of JAMA, Lilly and colleagues report a single academic center investigation that is of similar size and scope as the previous multicenter study, but has dramatically different results. Lilly et al examined the outcomes associated with implementation of ICU telemedicine among 6290 adult patients admitted to 7 ICUs using a stepped-wedge time series design. Tele-intensivists acted in complement with local clinicians to enforce daily goals, review adherence to evidence-based practices, and respond to bedside alarms. Admission to an ICU operating under the telemedicine model was associated with increased receipt of evidence-based preventive strategies and lower rates of ICU-acquired complications. Hospital mortality, ICU length of stay, and duration of mechanical ventilation also decreased. Importantly, telemedicine was associated with lower mortality both within ICUs over time and across ICUs during the same periods, strengthening the inference that the results are not due purely to time trends. The current study by Lilly et al and the previous study by Thomas et al included roughly the same number of ICUs and hospitals, used the same proprietary telemedicine system, and were both directed by academic leaders in the field. So how can these discordant results be reconciled? In the study by Thomas et al, there was limited physician buy-in and less than one-third of the patients received the full discretion of the telemedicine team for clinical care. In contrast, the telemedicine team in the study by Lilly and colleagues was allowed full discretion for all patients. Increased discretion may have led to more interventions directed at improving outcomes. Perhaps more importantly, the telemedicine program in the study by Thomas et al was not linked to any specific quality improvement programs. Instead, the teleintensivists provided mostly remote monitoring, intervening only when necessary—such that care via telemedicine was reactive rather than proactive. In contrast, the telemedicine program in the study by Lilly et al was tightly linked to specific quality improvement activities. The teleintensivists conducted real-time best-practice audits for selected evidence-based practices, reviewed care plans and daily goal sheets, and ensured adherence with the local intensivists’ plans. These interventions worked, as evidenced by the patients in the telemedicine program being more likely to receive evidence-based practices for prevention of ICU complications, demonstrating a plausible mechanism for the decrease in mortality. For this reason, the study by Lilly et al provides the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings. However, this study is not without limitations. The size of the adjusted mortality reduction is implausibly large, leaving open the possibility that some of the apparent benefit is due to differences in how severity of illness was measured between the 2 study groups. Moreover, the 7 ICUs in this study are part of one relatively well-resourced academic medical center that has a strong culture of quality improvement. It is unclear if these results could be replicated in hospitals with fewer resources to devote toward ICU quality. Additionally, all of the telemedicine physicians also worked in the target ICUs, which may have served to increase buy-in among local practitioners. These

The Practical Application of Theory and Research for Preventing Work Disability: A New Paradigm for Occupational Rehabilitation Services in China?

Theoretical frameworks for preventing work disability have evolved over the last decade and various experimental models have been tested in occupational rehabilitation settings. The successful application and uptake of the most recent research evidence in rehabilitation practices depend on a complex interplay of the decisions of multi-stakeholders, including their perceptions of the evidence, a proper regulatory framework for injury prevention, compensation and disability management; as well as the cultural and socioeconomic factors unique to each country (social context). This paper summarizes the scope of the work disability prevention field and describes the contextual barriers and support mechanisms for implementing evidence-based practices for disability prevention in China's national rehabilitation system. Expert opinions and relevant publications in the field were reasoned around key constructs of a translational model used to identify potential barriers and support platforms for research uptake in China. A crucial component of experimental models for disability prevention is to promote well-coordinated return to work actions centred in the workplace. Potential barriers and support mechanisms for implementing this and other evidence-based recommendations in China are described. The complexity of implementing a system-wide disability prevention model in a country as large and diverse as China is well-recognized. Improved efforts are thus required for international knowledge-sharing that can empower greater research utilization of effective disability prevention methods in China. The development of well-connected communities of practice might be a helpful strategy for enhancing stakeholders' perceptions, attitudes and collaborative efforts towards locally relevant and cultural sensitive solutions to work disability.

Mobilizing Communities to Implement Evidence‐Based Practices in Youth Violence Prevention: The State of the Art

Community mobilization can increase the effective implementation of evidence-based practices (EBPs) in youth violence prevention. These strategies bring together people and organizations in a community to try to solve or reduce a problem. They help communities address the challenges of identifying EBPs, disseminating them to local decision-makers, and then implementing and sustaining them if they are successful. Science-based systems for implementing EBPs such as PROSPER and Communities That Care can help to integrate this complex work in communities. Further insight about implementing EBPs in youth violence prevention is being developed through the CDC-funded Academic Centers for Excellence in Youth Violence Prevention. Community mobilization approaches for seven of these programs are discussed, highlighting successful approaches and challenges encountered.

Essential Elements for Community Engagement in Evidence‐Based Youth Violence Prevention

In the field of youth violence prevention, there has been increasing emphasis on "evidence based" programs and principles shown through scientific research as reaching their intended outcomes. Community mobilization and engagement play a critical role in many evidence-based programs and strategies, as it takes a concerted effort among a wide range of people within a community to alter behavior and maintain behavioral change. How do concerned individuals and groups within a community engage others within and outside of that community to effectively plan, develop and implement appropriate EB programs as well as evaluate the outcomes and impacts of locally developed programs yet to be proven? The authors discuss five elements essential for community engagement in evidence-based youth violence prevention based on their work in a university-community partnership through the Asian/Pacific Islander Youth Violence Prevention Center (API Center), a National Academic Center for Excellence on Youth Violence Prevention Center supported by the Centers for Disease Control and Prevention. They include: (a) aligning EBPs with a community's shared vision and values; (b) establishing an inclusive environment for the planning, implementation and evaluation of EBPs; (c) nurturing collaboration for increased effectiveness and efficacy of EBPs; (d) building adequate leadership and community capacity to develop and sustain EBPs; and (e) building a learning community for evaluation and self-reflection. The authors propose placing greater emphasis on "evaluative thinking" and organizational capacity for evaluation as we pursue evidence-based practices for youth violence prevention. This is especially important for ethnic groups for which an evidence base is not well established.

Statement on national worklife priorities

The National Institute for Occupational Safety and Health (NIOSH) WorkLife Initiative (WLI) [http://www.cdc.gov/niosh/worklife] seeks to promote workplace programs, policies, and practices that result in healthier, more productive employees through a focus simultaneously on disease prevention, health promotion, and accommodations to age, family, and life stage. The Initiative incorporates the Institute's foundational commitment to workplaces free of recognized hazards into broader consideration of the factors that affect worker health and wellbeing. Workplace hazards, such as physical demands, chemical exposures, and work organization, often interact with non-work factors such as family demands and health behaviors to increase health and safety risks. New workplace interventions being tested by the first three NIOSH WLI Centers of WorkLife Excellence are exploring innovative models for employee health programs to reduce the human, social, and economic costs of compromised health and quality of life. Many parties in industry, labor, and government share the goals of improving employee health while controlling health care costs. NIOSH convened a workshop in 2008 with representatives of the three Centers of Excellence to develop a comprehensive, long-range strategy for advancing the WorkLife Initiative. The recommendations below fall into three areas: practice, research, and policy. Responding to these recommendations would permit the WorkLife Center system to establish a new infrastructure for workplace prevention programs by compiling and disseminating the innovative practices being developed and tested at the Centers, and elsewhere. The WLI would also extend the customary scope of NIOSH by engaging with multiple NIH Institutes that are already generating research-to-practice programs involving the working-age population, in areas such as chronic disease prevention and management. Research to Practice (r2p) is a concept focused on the translation of research findings, technologies, and information into evidence-based prevention practices and products that are adopted in the workplace or other "real-world" settings. NIOSH's goal is to overcome the translational issues that now prevent state-of-the-art occupational health, health promotion, and chronic disease research findings from benefiting working age populations immediately, regardless of workplace size, work sector, or region of the country.