Guideline Implementation Interventions Research Articles

Impact of NHAP Guideline Implementation Intervention on Staff and Resident Vaccination Rates

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates. Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding. No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates. External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.

Analyse qualitative et quantitative des déterminants à l’application de recommandations professionnelles (RP) par les médecins

Background The effectiveness of Clinical Practice Guideline (CPG) implementation interventions could be improved by their adaptation to facilitators of and barriers to practice change in each setting. Very few is known about these local factors in French hospitals. Our objectives were to identify the facilitator factors of and barriers to physician's adherence to CPG in internal medicine wards in France and to determine the factors most strongly statistically associated to CPG adherence. Methods Combined qualitative and quantitative methods. Two CPGs were chosen as examples. The settings were internal medicine wards of hospitals of the Aquitaine region voluntary to participate. Qualitative analyses were conducted in the internal medicine wards of 5 hospitals in the Aquitaine region selected among the 12 voluntary hospitals to represent the variability of situations. Quantitative analysis A questionnaire was constituted by the factors retrieved through the qualitative analyses and a previous literature review as barriers or facilitator factors to physician's adherence to CPG and asked the physicians on the degree of CPG adherence. It was sent to each physician of the internal medicine wards of the 12 voluntary hospitals. The responses to the questionnaire allowed the analysis of the frequency of each factor and the strength of the statistical association between these factors and CPG adherence. Results These analyses focused on the importance of the management, particularly the role of ward head and of the exchange between physicians. The attitude to CPGs varied according to the individual positionnement on the professional hierarchy, function of the quantity of research activities and of the local, regional and national radiance of the ward. Organisational difficulties as professionals and patients turn over, work overload, lack of coordination between wards were organisational barriers to CPG adherence. The quantitative analysis confirmed the role of managerial and organisational factors in the CPG adherence. Conclusion Following step was to validate a tool of barriers to CPG adherence identification and to study the effectiveness of this a priori identification in improving CPG adherence.

Implementing a hospital guideline on pneumonia: a semi-quantitative review

To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting. Pubmed, the Cochrane Library, the Cochrane Effective Practice and Organization of Care specialized register, EMBASE and CINAHL. Hospital-based trials studying the effect of guidelines on compliance with care processes, clinical and/or economic outcomes in the treatment of CAP together with a description of their implementation interventions. Two independent reviewers extracted and categorized utilized implementation interventions, assessed intensity of use and calculated changes for process of care variables, clinical and economical outcomes. Correlations between interventions and improvement of outcomes were assessed by means of Spearman's rho-test and Mann-Whitney U-test. In 27 included studies, educational meetings (21/27) and distribution of written material (14/27) were the two most used interventions. Most individual studies show positive overall results, but taken together, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. Only audit and feedback showed a significant negative influence on the improvement rate of length of stay (p = 0.003; n = 20). Other hospital-specific factors are likely to have a higher impact on the rate of improvement than the implementation interventions alone. Describing which interventions are most successful is unlikely to be correct without taking these hospital-specific factors into account. Future research should focus on how to identify and define these factors and how to adapt the intervention to hospital-specific factors.

Missed opportunities for noninvasive positive pressure ventilation: A utilization review

Background Although noninvasive positive pressure ventilation (NPPV) improves outcomes in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), it may be underutilized outside the controlled trial setting. Purpose The purpose of this study is to determine the proportion of patients who met criteria for a trial of NPPV but were emergently intubated and mechanically ventilated without receiving a trial of NPPV. Methods We retrospectively reviewed charts of patients who were intubated and ventilated or who received NPPV on admission to one intensive care unit and who had an intensive care unit admitting diagnosis of either exacerbation of COPD or CHF during the period from November 1998 to July 2003. Results Of the 243 patients who had an admitting diagnosis of COPD or CHF, 59 (24.3%) met explicit criteria for a trial of NPPV. Only 20 (33.9%) of 59 had a trial of NPPV. The remaining 39 (66%) of 59 did not receive a trial of NPPV and were intubated. Interpretation Nearly two thirds of patients who appeared to meet criteria for NPPV did not receive a trial of this intervention. There is an opportunity to improve the use of NPPV in these patients. Systematic knowledge translation strategies such as guideline implementation and interactive educational interventions may optimize the appropriate use of NPPV.