Implementation Of Evidence-based Care Research Articles

Chronic, Noncancer Pain Care in the Veterans Administration: Current Trends and Future Directions.

The Veterans Health Administration has always been a leader in the innovation and implementation of evidence-based care. The use of the stepped care model of chronic pain has led to several novel interventions and strong practices in the last several years at each level of care with regard to education, use of technology, and increasing access to evidence-based care (eg, behavioral health, interdisciplinary teams). The Whole Health model is also being implemented nationwide and has the potential to significantly affect chronic pain treatment in the coming decade.

Nursing Practice Based on Evidence-Based Concepts to Prevent Enteral Nutrition Complications for Critically Ill Neurosurgical Patients.

PurposeTo explore the practical value of enteral nutrition care guided by evidence-based concepts in preventing enteral nutritional complications in critically ill neurosurgical patients.MethodsThree hundred critically ill patients from March 2020 to October 2021 from our neurosurgery department were included in the study. Patients were divided into a control group (March to December 2020, n = 150) and a study group (January to October 2021, n = 150) according to the order of their admission. The control group received conventional enteral nutrition care, and the study group received enteral nutrition care based on evidence-based concept guidance. The levels of serum nutritional indicators [hemoglobin (Hb), albumin (ALB), and total protein (TP)], feeding compliance rate, the incidence of complications (gastric retention, bloating, diarrhea, reflux, vomiting, aspiration, stress ulcers, etc.), and prognosis during the observation period were compared between the two groups. The scores of the questionnaire of knowledge, attitude, and practice on nutrition among neurosurgical nurses before and after the implementation of evidence-based care were compared among nursing staff in the study group.ResultsAt 1 and 2 weeks after enrollment, Hb, ALB, and TP levels were lower in both groups than before enrollment in the same group (P < 0.05). At 2 weeks after enrollment, Hb, ALB, and TP levels were higher in both groups than at 1 week after enrollment in the same group (P < 0.05). At 1 and 2 weeks after enrollment, Hb, ALB, and TP levels were higher in the study group than in the control group (P < 0.05). At 7 days after feeding, the feeding compliance rate was higher in the study group (94.67%) than in the control group (70.00%) (P < 0.05). The total complication rate was lower in the study group (8.00%) than in the control group (16.00%) (P < 0.05). The percentage of good prognosis was higher in the study group (34.00%) than in the control group (23.33%) (P < 0.05). After the implementation of evidence-based care, caregivers in the study group scored higher on nutrition knowledge, nutrition attitudes, and nutrition practices than those before the implementation (P < 0.05).ConclusionThe implementation of evidence-based nursing interventions in critically ill neurosurgical patients based on evidence-based concepts is of great clinical value in correcting their nutritional status, preventing enteral nutritional complications, improving prognosis, and enhancing the nutritional knowledge, attitudes, and practices of nursing staff.

Which factors determine clinicians\u2019 policy and attitudes towards medication and parent training for children with Attention-Deficit/Hyperactivity Disorder?

Behavioral parent and teacher training and stimulant medication are recommended interventions for children with attention-deficit/hyperactivity disorder (ADHD). However, not all children with ADHD receive this evidence-based care, and the aim of the current study was to find out why. More specifically, we investigated clinicians’ policy, guideline use, and attitudes towards medication and parent training when treating children with ADHD, as well as several factors that could affect this. A total of 219 Dutch clinicians (mainly psychologists, psychiatrists and educationalists) completed a survey. Clinicians were likely to recommend medication more often than parent training, and clinicians’ policy to recommend medication and parent training was positively associated with their attitudes towards these interventions. Less experienced clinicians and those with a non-medical background reported lower rates of guideline use, whereas clinicians with a medical background reported less positive attitudes towards parent training. Furthermore, a substantial portion of the clinicians based their decision to recommend parent training on their clinical judgement (e.g., prior estimations of efficacy, perceived low abilities/motivation of parents), and many clinicians reported barriers for referral to parent training, such as waiting lists or a lack of skilled staff. To achieve better implementation of evidence-based care for children with ADHD, guidelines should be communicated better towards clinicians. Researchers and policy-makers should further focus on barriers that prevent implementation of parent training, which are suggested by the discrepancy between clinicians’ overall positive attitude towards parent training and the relatively low extent to which clinicians actually advise parent training.

The annual dementia review: exploring current practice in primary care.

Dementia is a global public health challenge, the significant consequences of which are recognised in global and national health policies. Despite approaches to improve the implementation of evidence-based dementia care in primary care and the inclusion of indicators for dementia in the Quality and Outcomes Framework (QOF), there is consistent evidence that people with dementia and their family carers lack access to care which meets their needs. This study aims to explore current practice regarding the annual dementia review in primary care by investigating: 1) what 'should' be happening in annual dementia reviews; 2) how dementia reviews are delivered in a sample of general practices; 3) the barriers and facilitators to the implementation of evidence-based care in dementia reviews; and 4) the experience of these reviews from the perspectives of people with dementia and their informal carer(s). Qualitative methods will be used. In the first stage, semi-structured interviews with national and regional experts in dementia policy and healthcare will be used to explore what 'should' be happening in an annual dementia review. In the second stage, interviews with primary healthcare team members will explore how annual dementia reviews are delivered in a sample of practices in North East England. Interviews with people with dementia and their carers will then be used to explore how reviews are experienced by service users. Thematic analysis will be used to analyse data. Key themes from the first stage will be presented and their implications in primary care discussed. The research plan for the second stage will be presented.

Challenges to trauma care delivery for Australian and New Zealand trauma clinicians

IntroductionThe availability and implementation of evidence-based care is essential to achieving safe, quality trauma patient outcomes. Little is documented, however, about the challenges trauma clinicians face in their day-to day practice, or their views on the availability of evidence. This paper presents the most significant clinical practice challenges reported by multidisciplinary trauma care professionals in Australia and New Zealand, in particular those that may be resolved with focussed research or enhanced implementation activity. MethodsAn exploratory survey of trauma professionals from relevant Australia and New Zealand professional organisations was conducted between September 2018 and February 2019 using the Snowballing Method. Participants were recruited via a non-random sampling technique to complete an online survey. Thematic analyses were conducted. ResultsThere were nine significant clinical practice challenge themes in trauma care, arising from 287 individual clinical practice challenges reported. The most reported being clinical management (bleeding, spinal, older patients) and operationalisation of the trauma system. There was no consensus as to the availability of evidence to guide each theme. ConclusionFuture research should seek to address the clinical practice challenge of Australian and New Zealand trauma community to enable safe, quality trauma patient outcomes.

EDITORIAL: The Value of Learned Journals for Health Professionals

As we celebrate the twenty-year anniversary of the African Journal of Reproductive Health (AJRH) this year1, it is apt to consider the changing role of learned journals over the last two decades specially with increasing access to the worldwide web. A much-needed and welcome democratization in the availability of information has been accompanied regrettably by a concomitant overload from continual bombardment by email messages and postings from social media and at websites. As much of that information is not sieved, false news spread at an alarming rate with potentially detrimental effects on clinical consultations when misinformed patients query clinical decisions of health providers and demand inappropriate interventions specially drugs with supposedly miracle effects2. Whereas it is imperative to be selective in accessing information sources to avoid fake news, this approach is becoming difficult lately with the unfortunate official promotion of alternative facts in a post-truth context3. With triage becoming increasingly difficult, there is renewed interest in professional journals and textbooks which are now aimed at not only students but also health planners and development practitioners4. For journal contents, there is the delicate ‗town and gown‘ balance between service provision and academia but that gap is closing with the implementation of evidence-based care. Health journals that developed from broadsheets and newsletters of professional associations5 justifiably continue their role of mouthpiece by including items such as minutes of annual general meeting, reports from committees and administrative notices. Through ownership of a learned journal, a professional association demonstrates that it is not merely a trade union but it is also desirable for the journal editor to be given full independence free from pressure regarding both contents, specially as pertaining to standpoints of the professional association, and financial constraints necessitating advertising revenue. During the first decade of the African Journal of Reproductive Health, three leading medical journals in North America had to revoke their editors over editorial independence6. Peer review of manuscripts is an integral part of the editorial process to ensure the quality of articles published in a learned journal. Whereas guidelines exist, problems can arise in their implementation7. Having the final word, the editor should be impartial, abandon personal interests and neither give-in to pressure groups nor favor friends: a constraining situation similar to that faced by the Speaker in a Westminster-style parliament8. For service provider, policy maker or planner, it is much easier to shoot from the hip by taking decisions spontaneously on the spot as opposed to consulting the health literature for up-to-date evidence. With the electronic age, the vade-mecum in the pocket of the white coat of the clinician has often been replaced by bookmarks on personal digital devices to access reliable websites for official guidelines and online journals. Unfortunately, a substantial portion of the health literature is accessible only upon payment thereby making it largely inaccessible in developing countries where practitioners are those most in need. The decision-making process, whether at the bedside or policy desk, should ideally draw upon evidence specially from research findings9,10. Journal articles should clearly state their contribution to the existing body of knowledge. Therefore, the publication of research articles is part of a two-way process: reporting of findings to supplement existing systematic reviews which must be used to formulate subsequent research projects that will uncover new facts11. With the dearth of pertinent findings from low and middle-income countries, this issue is crucial to generate the information database for their implementation of evidence-based practices. With the current trend towards quantification of all issues, metrics are assuming more importance in assessing journals through proxy indices, such as impact factor, which have their own limitations. It should not be forgotten that, in the first place, a journal should meet the specific needs of its target readership whereas prominence on the worldwide web is desirable for generating awareness of journal contents during literature searches. Having its origins within a research centre, the African Journal of Reproductive Health has had an exemplary path as pertaining to editorial independence, quarterly periodicity of publication and quality of articles besides availability of issues at a dedicated website and inclusion in PubMed from the very beginning. Having been recognized as the leading regional journal in its field, the challenge now lies in consolidating its multidisciplinary approach, with a wide perspective on reproductive health, to promote its utilization for policy formulation in the quest for achieving the health-related sustainable development goals.

A Test of the ARCC© Model Improves Implementation of Evidence-Based Practice, Healthcare Culture, and Patient Outcomes.

Although several models of evidence-based practice (EBP) exist, there is a paucity of studies that have been conducted to evaluate their implementation in healthcare settings. The purpose of this study was to examine the impact of the Advancing Research and Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians' EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the western United States. A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full implementation of the ARCC Model. The study was conducted at a 341-bed acute care hospital in the western region of the United States. The sample consisted of 58 interprofessional healthcare professionals. The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare professionals' EBP beliefs, EBP implementation, and organizational culture were measured with valid and reliable instruments. Patient outcomes were collected in aggregate from the hospital's medical records. Findings indicated significant increases in clinicians' EBP beliefs and EBP implementation along with positive movement toward an organizational EBP culture. Study findings also indicated substantial improvements in several patient outcomes. Implementation of the ARCC Model in healthcare systems can enhance clinicians' beliefs and implementation of evidence-based care, improve patient outcomes, and move organizational culture toward EBP.

Telemedicine REsuscitation and Arrest Trial (TREAT): A feasibility study of real-time provider-to-provider telemedicine for the care of critically ill patients.

BackgroundProtocol-based resuscitation strategies in the Emergency Department (ED) improve survival for out-of-hospital cardiac arrest (OHCA) and severe sepsis but implementation has been inconsistent.ObjectiveTo determine the feasibility of a real-time provider-to-provider telemedical intervention for the treatment of OHCA and severe sepsis.Materials and methodsA three-center pilot study utilizing a “hub-spoke model” with an academic medical center acting both as the hub for teleconsultation as well as a spoke hospital enrolling patients. Eligible patients were adults presenting with either return of spontaneous circulation (ROSC) following OHCA or with severe sepsis. Telemedical encounters were monitored for quality of interface and patient level data (demographics, physiologic, laboratory, treatment) were abstracted.ResultsOver a 12-week period, there were 80 text alerts. Of 38 OHCA alerts, 13 achieved ROSC (34.2%), 85% underwent teleconsultation (11/13). Of 42 “lactate ≥4 mmol/L” alerts, 33.3% (14/42) were determined to have severe sepsis and underwent teleconsultation. Mean time from OHCA teleconsultation request to live connection: 3.7 min (95% CI 1.6–5.8); mean call duration: 71.7 min (95% CI 34.6–108.8). Mean time from sepsis teleconsultation request to connection: 8.4 min (95% CI 4.5–12.3); mean call duration: 61.5 min (95% CI 37.2–85.8).DiscussionTelemedicine provides a robust and reliable means of quickly bringing expertise virtually to the bedside at the most proximal point in a patient’s hospital care.ConclusionsReal time ED-based telemedical consultation for patients with ROSC after OHCA or severe sepsis has the potential to improve the dissemination and implementation of evidence-based care.

Generation of Evidence and Translation Into Practice: Lessons Learned and Future Directions.

The generation, validation, and then translation of definitive evidence to bedside evidence-based practice is inconsistent and presents many challenges to emergency department (ED) researchers and clinicians. This is particularly true for diagnostic imaging in the ED, where benefits and drawbacks may be difficult to assess in the chaotic ED setting. This article describes, in large part, the experience of the Pediatric Emergency Care Applied Research Network (PECARN) in deriving and validating the traumatic brain injury prediction rules and how PECARN is translating these prediction rules into clinical practice. Furthermore, we discuss the potential for patient/parent shared decision-making with a focus on patient-centered outcomes in ED research and the role this shared decision-making may play in enhancing knowledge translation and implementation of evidence-based care in the ED.

Power of sharing the patient journey in implementation of evidence-based care in emergency departments

Power of sharing the patient journey in implementation of evidence-based care in emergency departments

Creative Approaches to Increasing Hospital-Based Nursing Research

Magnet-designated and aspiring hospitals use research and evidence-based practice initiatives to demonstrate new knowledge and innovation, a key component of the Magnet Recognition Program. Four creative approaches to supporting and conducting institutional nursing research and the implementation of evidence-based care are illustrated, along with examples of successful nurse staff-led projects.

A qualitative study of ethical, medico-legal and clinical governance matters in Australian telehealth services

We examined how Australian telehealth service providers perceived and addressed ethical, medico-legal and clinical governance matters arising from service delivery. Thirty-seven telehealth clinicians and managers were interviewed and a qualitative content analysis was conducted. The services covered six Australian jurisdictions and a range of clinical disciplines. There were 11 medical specialities, surgery, mental health, paediatrics, nursing and allied health. Thirty services (83%) used video consulting and 25 (68%) delivered services to rural areas. Telehealth was reported to be beneficial by reducing adverse events, improving health outcomes, offering increased patient choice of service delivery, and improving access to services for rural areas and home care. There were observations of gains or no change in patient-provider rapport compared to face-to-face communication, with some patients reportedly preferring video. Those interviewed reported some problems with privacy and security, and variable informed consent practices. No examples of malpractice were raised, although there was a common misperception that distant providers were not responsible for clinical care. With respect to clinical governance, telehealth was seen as enabling improved quality, integration and implementation of evidence-based care, and to be a major support for the rural health workforce. Although there were potential ethical, medico-legal and governance problems in Australian telehealth services, these had been easily managed in practice.

Evidence-Based Practice Implementation Strategy

The Hospital of the University of Pennsylvania Model of Excellence in Nursing Professional Practice serves to fully integrate the role of the clinical nurse specialist (CNS) in the implementation of evidence-based care and the role of organizational change agent. In this role, the CNS is responsible for the identification and remedy of system-wide challenges to optimal quality care, mentorship of clinical nurses both as clinicians and as leaders, and enhancement of interdisciplinary partnerships. Integrating the CNS role as the nursing department knowledge keepers, knowledge seekers and knowledge disseminators able to proactively develop and enhance interdisciplinary partnerships required systematic educational sessions and use of outcome measurement tools. Resources have included role development seminars, individual mentoring and standardization of role expression, across service lines. Development and implementation of an outcome measurement tool has served to further quantify the contribution of the CNS and standardized role implementation across service divisions. This dedication of resources has resulted in a significant number of unit-based and system-wide CNSs, serving as a significant support to the clinical nurse's practice and leadership development. This article will describe some of the processes used to enhance the role of the CNS implementing change and practice improvement at the Hospital of the University of Pennsylvania.

Pros and Cons of Composite Endpoints in Anesthesia Trials

Pros and Cons of Composite Endpoints in Anesthesia Trials

Making sense of primary care practices’ capacity for change

A deeper understanding of the forces that shape the motivation and willingness of primary care practices to adopt and implement new procedures-their "capacity for change"-may better guide development of interventions to foster adoption and implementation of evidence-based care. This study applies and evaluates the utility of a previously described framework for making sense of this complex construct in a diverse sample of primary care practices. A multidisciplinary team of 3 analysts examined ethnographic field notes that describe 15 single-physician or multiphysician practices in different organizational settings. Examples of the 4 components within the framework (ie, staff motivations, resources, opportunities for change, and external influences) and their interactions were identified. Cross-practice comparisons identified emerging themes relevant to capacity for change. Not surprisingly, variation among examples of individual components of change capacity across practices was present. Patterns among these components, however, seemed less informative in making sense of practices' capacity for change than patterns across component interactions. For example, the ability of practice members to recognize and act on opportunities for change seemed to be shaped by the extent to which motivations were broadly shared within the practice and by tangible and intangible resources (eg, leadership style, relationships among practice members, and financial resources of the practice). Revised operational definitions for framework components and careful reflection on the nature of their interactions helped make sense of practices' capacity for change in our sample and will enable future hypothesis testing to refine our understanding of factors that influence the translation of scientific knowledge in primary care settings.

Evidence Rocks in Long-term Care, But Does It Roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.

Women, Acute Ischemic Heart Disease, and Antithrombotic Therapy

There now exists an extensive and growing literature examining gender-based differences in the pathobiology, presentation, treatment patterns, and clinical outcomes of ischemic heart disease (IHD). IHD is a dominant mode of death for women,1 and, for >20 years, more women than men die annually from IHD.2 The first manifestation of IHD in women is frequently myocardial infarction or sudden cardiac death.2 A better understanding of the spectrum of issues—from pathophysiology through implementation of evidence-based care—among women with IHD is a public health imperative. Article p 2822 Recently, many observations have converged around a common set of themes in the care of women with IHD, especially acute IHD. Lansky et al3 have pointed out that women with degrees of obstructive coronary artery disease comparable to those of men receive less revascularization. From the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) registry, we know that women presenting with high-risk non–ST-segment–elevation acute coronary syndromes (primarily myocardial infarction) are less likely than men to undergo an early invasive management strategy despite being at a higher baseline risk.4 Women with non–ST-segment–elevation acute coronary syndromes are less likely than men to receive recommended evidence-based medications and cardiac procedures, again despite being at higher baseline risk.5 However, there are also challenges in evaluating and deciding on treatments for women presenting with acute coronary syndromes. Roe and colleagues6 have shown that women presenting with non–ST-segment–elevation acute coronary syndromes have a greater likelihood of nonobstructive disease than do men, and the Women’s Ischemia Syndrome Evaluation (WISE) investigators have compiled a substantial body of work suggesting that the pathobiology of IHD differs in women compared with men.7 All of this makes it imperative that we perform enough research in women …

The Challenges of Transferring Evidence-Based Dentistry into Practice

The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Though clinicians embrace this concept, its implementation in clinical practice has been slow. In this paper, barriers against the implementation of evidence-based care are examined and possible solutions are offered.

The Challenges of Transferring Evidence-Based Dentistry into Practice

The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Although clinicians embrace this concept, its implementation in clinical practice has been slow. In this article, barriers against the implementation of evidence-based care are examined and possible solutions are offered. The dental profession is committed to providing the best possible dental care for patients. This is proving to be more complex due to a virtual "information explosion" on new therapies, techniques, and materials; increased consumer understanding of treatment possibilities and therapeutic outcomes; and changing sociodemographic patterns. Although the profession advocates the importance of evidence-based dental disease prevention and treatment, practitioners have been slow to implement this concept. In 2003, the California Dental Association (CDA) formulated an evidence-based dentistry (EBD) action plan that included the formation of a task force to monitor EBD efforts and implement programs to educate CDA members on this methodology. The challenges of transferring EBD into clinical practice were key issues addressed by the task force, and much of their deliberations and perspectives are reflected in this article. Possible solutions for eliminating barriers against evidence-based care will also be explored.

Introducing an integrated care pathway for the last days of life

Integrated care pathways (ICPs) are multiprofessional documents designed to enable the implementation of evidence-based care and support the practical delivery of clinical governance. However, the implementation of care pathways is resource intensive and few evaluations have been conducted with respect to these areas or to the efficacy of care pathways to change practice and improve outcomes in care. This project sought to address these issues and the report outlines the approach taken by a palliative care team in South Wales, UK, to implement a care pathway for the dying throughout a district general hospital and six community hospitals. Dying can be a complex area of care and changing practice can be challenging, therefore a PRINCE Project management approach was taken and a full-time project nurse employed for the life of the project. This paper describes the strategies used to approach implementing a care pathway and provides a template for other teams who may embark on similar projects. At the end of the project, the care pathway was successfully implemented and provided demonstrable outcomes of care for those dying from cancer and nonmalignant diseases. Strikingly, a large number of patients dying from nonmalignant disease were cared for via the pathway, which was not expected.