Implementation Of New Guidelines Research Articles

Abstract 13822: Guideline Directed Medical Treatment in Patients With Heart Failure in China

Introduction: Patients with Heart Failure (HF) are often treated at less than target dose or lack Guideline Directed Medical Treatments (GDMT), this has also been reported for patients with HF with reduced ejection fraction (HFrEF) in China. However, data on treatment patterns in different subgroups by disease onset and ejection fraction phenotypes is scarce. Research Question: What are the patient characteristics and treatment for HF in China in relation to concurrent guidelines? Aim: To describe characteristics of incident and prevalent patients with HF and treatment with GDMT (RAASi, BB and MRAs) for HFrEF patients in China prior to SGLT2i approval for HF. Methods: Data from the Heart Failure Registry at the Chinese Cardiovascular Association Heart Failure Center from Jan. 1, 2018 to July 31, 2021 was used. Data on the first 10 new HF inpatients each month is recorded on a case report form at discharge and 1-, 3- and 12-months follow-up. GDMT at discharge and 12 months was described for HFrEF patients. Results: We identified 32047 patients with HF: 21698 incident and 10349 prevalent cases, 13117 (40.9%) HFrEF, 6,368 (19.9%) HFmrEF, 10826 (33.8%) HFpEF and 1736 (5.4%) had no EF measurement. Mean age was 64.8 years in incident and 66.1 years in prevalent patients. A larger proportion of HFpEF patients were women than in other EF phenotypes. At discharge, 71.2% of incident and 75.7% of prevalent patients were treated with RAASi, 77.9% and 81.2% were treated with BB and 65.7% and 75.8% with MRA. Treatment was consistently lower at 12 months. In HFrEF 65.6% and 69.2% of incident and prevalent patients had three GDMTs at discharge; 37.3% and 39.9% at 12 months. Patient target/maximum tolerated dose for incident HFrEF patients was reached for17.6% (RAASi), 28.3% (BB) and 48.7% (MRA); for prevalent this was 24.8%, 38.4% and 50.8%. Conclusions: In this study on HF patients in Chinese clinical practice, 40% had HFrEF whereas the majority had preserved or mildly reduced EF. In the HFrEF patients, less than half of patients had three concurrent GDMTs at 12 months. Moreover, few patients received the target dose at 12 months and many discontinued treatment. These results show an urgent need for improved treatment strategies and effective implementation of new guidelines in China.

Increased frequency of false-positive bacterial detection after implementation of new guidelines for large-volume delayed sampling of platelets.

The updated guidance for improving bacterial detection (BD) of platelets has included the implementation of large-volume delayed sampling (LVDS) with the addition of anaerobic culture bottles (BPNs) and sampling of each platelet split product. The frequency of BD was reviewed during this LVDS time period in comparison with pre-LVDS and the Post-Approval Surveillance Study of Platelet Outcomes, Release Tested (PASSPORT) study (when BPNs were last used). There was more than a twofold increase in bottles inoculated per collection during LVDS, with an almost fivefold increase in sample volume collected. During LVDS, the concordance of split products within an initial reactive collection was only 8.7%. There was no difference in LVDS aerobic culture bottle (BPA) true positives (TPs), but there was a significant increase in LVDS false positives (FPs), p < .0001, compared to both PASSPORT and pre-LVDS, respectively. There was an increase in BPN TPs during LVDS (p < .05 compared to PASSPORT), with predominance of Cutibacter acnes (C. acnes), noted exclusively in BPN, and accounting for more than two-fifths of all organisms detected. Time to alarm during LVDS for TPs had two peaks with one due to C. acnes at 96 h compared to 17 h for non-C. acnes. The high FP frequency, along with low clinical significance of TPs found in BPNs, has led to the needless discard of inventory, as the utility of BPNs in BD for platelets is yet to be established and may require much larger studies.

Clinical Application of Artificial Intelligence for Non-melanoma Skin Cancer.

The development and implementation of artificial intelligence is beginning to impact the care of dermatology patients. Although the clinical application of AI in dermatology to date has largely focused on melanoma, the prevalence of non-melanoma skin cancers, including basal cell and squamous cell cancers, is a critical application for this technology. The need for a timely diagnosis and treatment of skin cancers makes finding more time efficient diagnostic methods a top priority, and AI may help improve dermatologists' performance and facilitate care in the absence of dermatology expertise. Beyond diagnosis, for more severe cases, AI may help in predicting therapeutic response and replacing or reinforcing input from multidisciplinary teams. AI may also help in designing novel therapeutics. Despite this potential, enthusiasm in AI must be tempered by realistic expectations regarding performance. AI can only perform as well as the information that is used to train it, and development and implementation of new guidelines to improve transparency around training and performance of algorithms is key for promoting confidence in new systems. Special emphasis should be placed on the role of dermatologists in curating high-quality datasets that reflect a range of skin tones, diagnoses, and clinical scenarios. For ultimate success, dermatologists must not be wary of AI as a potential replacement for their expertise, but as a new tool to complement their diagnostic acumen and extend patient care.

Implementation of the ESC STEMI guidelines in female and elderly patients over a 20-year period in a large German registry

AimsWe investigated the implementation of new guidelines in ST-segment elevation myocardial infarction (STEMI) patients in a large real-world patient population in the metropolitan area of Berlin (Germany) over a 20-year period.MethodsFrom January 2000 to December 2019, a total of 25 792 patients were admitted with STEMI to one of the 34 member hospitals of the Berlin-Brandenburg Myocardial Infarction Registry (B2HIR) and were stratified for sex and age < 75 and ≥ 75 years.ResultsThe median age of women was 72 years (IQR 61–81) compared to 61 years in men (IQR 51–71). PCI treatment as a standard of care was implemented in men earlier than in women across all age groups. It took two years from the 2017 class IA ESC STEMI guideline recommendation to prefer the radial access route rather than femoral until > 60% of patients were treated accordingly. In 2019, less than 60% of elderly women were treated via a radial access. While the majority of patients < 75 years already received ticagrelor or prasugrel as antiplatelet agent in the year of the class IA ESC STEMI guideline recommendation in 2012, men ≥ 75 years lagged two years and women ≥ 75 three years behind. Amongst the elderly, in-hospital mortality was 22.6% (737) for women and 17.3% (523) for men (p < 0.001). In patients < 75 years fatal outcome was less likely with 7.2% (305) in women and 5.8% (833) in men (p < 0.001). After adjustment for confounding variables, female sex was an independent predictor of in-hospital mortality in patients ≥ 75 years (OR 1.37, 95% CI 1.12–1.68, p = 0.002), but not in patients < 75 years (p = 0.076).ConclusionIn-hospital mortality differs considerably by age and sex and remains highest in elderly patients and in particular in elderly females. In these patient groups, guideline recommended therapies were implemented with a significant delay.Graphical abstract

Neonatal Outcomes since the Implementation of No Routine Endotracheal Suctioning of Meconium-Stained Nonvigorous Neonates.

This study aimed to evaluate the effect of the 2015 Neonatal Resuscitation Program recommendations of no routine endotracheal suctioning for nonvigorous neonates on the incidence of meconium aspiration syndrome (MAS) and death. We hypothesized that the revised guidelines have not changed the outcome of MAS/death. This was a single-center retrospective cohort study. We recorded data on nonvigorous neonates born at gestational age > 37 weeks, who were divided into period 1, n = 95 (before the new guidelines, January 1, 2013-December 31, 2015) and prospective period 2, n = 91 (after the implementation of new guidelines, January 1, 2017-December 31, 2020). Primary outcomes included MAS and death. Secondary outcomes included respiratory neonatal intensive care unit (NICU) admission, length of NICU stay, and feeding difficulties. No significant differences in the occurrence of MAS (11 vs. 17%) (odds ratio [OR] of 1.46 [95% confidence interval [CI]: 0.59-3.55]) or death (1 vs. 3%) (OR of 2.00 [95% CI: 0.18-21.57]) among the two periods were observed. In period 2, there was an increased NICU respiratory admission (37 vs. 61%), with an OR of 2.31 (95% CI: 1.10-4.84). More neonates in period 2 required subsequent intubation for respiratory failure in the delivery room (12 vs. 28%) with an OR of 2.03 (95% CI: 1.02-4.51); p-value of 0.05. Our study did not observe a significant difference in the incidence of MAS or death between the two periods since the 2015 guidelines. However, the incidence of NICU respiratory admission increased. · Nonvigorous neonates born through MSAF who did not undergo ET suctioning soon after birth did not have increased incidence of MAS or death, but had increased NICU respiratory admissions.. · A large Multi-center RCT may give more clear verdict on the outcomes of these newborns..

Introduction of Small Stitch Small Bite technique: a retrospective long-term follow-up

PurposeStandardization of abdominal wall closure is suggested to improve quality and reduce the risk for late abdominal wall complications. The purpose of this study was to explore the impact of a structured introduction of guidelines for abdominal wall closure on the rates of incisional hernia and wound dehiscence.MethodsAll procedures performed via a midline incision in 2010–2011 and 2016–2017 at Capio St Göran’s Hospital were identified and assessed for complications and risk factors.ResultsSix hundred two procedures were registered in 2010–2011, and 518 in 2016–2017. Four years after the implementation of new guidelines, 93% of procedures were performed using the standardized technique. There was no significant difference in the incidence of incisional hernia or wound dehiscence between the groups. In multivariate Cox proportional hazard analysis, BMI > 25, wound dehiscence, and postoperative wound infection were found to be independent risk factors for incisional hernia (all p < 0.05). In multivariate logistic regression analysis, male gender and chronic obstructive pulmonary disease were risk factors for wound dehiscence (both p < 0.05).ConclusionsThe present study failed to show a significant improvement in rates of incisional hernia and wound dehiscence after the introduction of Small Stitch Small Bites. When introducing a new standardized technique for closing the abdomen, education and structural implementation of guidelines may have an impact in the long run. The risk factors identified should be taken into consideration when closing a midline incision to identify patients with high risk.

Vitamin D Status in Pediatric and Young Adult Cystic Fibrosis Patients. Are the New Recommendations Effective?

Introduction: In recent years, guidelines for vitamin D supplementation have been updated and prophylactic recommended doses have been increased in patients with cystic fibrosis (CF). Objective: To evaluate safety and efficacy of these new recommendations. Results: Two cohorts of pancreatic insufficient CF patients were compared before (cohort 1: 179 patients) and after (cohort 2: 71 patients) American CF Foundation and European CF Society recommendations were published. Cohort 2 patients received higher Vitamin D doses: 1509 (1306–1711 95% CI) vs 1084 (983–1184 95% CI) IU/Day (p < 0.001), had higher 25 OH vitamin D levels: 30.6 (27.9–33.26 95% CI) vs. 27.4 (25.9–28.8 95% CI) ng/mL (p = 0.028), and had a lower prevalence of insufficient vitamin D levels (<30 ng/mL): 48% vs 65% (p = 0.011). Adjusted by confounding factors, patients in cohort 1 had a higher risk of vitamin D insufficiency: OR 2.23 (1.09–4.57 95% CI) (p = 0.028). Conclusion: After the implementation of new guidelines, CF patients received higher doses of vitamin D and a risk of vitamin D insufficiency decreased. Despite this, almost a third of CF patients still do not reach sufficient serum calcidiol levels.

Uptake of Contraception Among Adolescent Girls and Young Women PrEP Clients: Leveraging the Opportunity to Strengthen HIV and Sexual and Reproductive Health Integration.

The introduction of oral pre-exposure prophylaxis (PrEP) for HIV prevention was a major breakthrough in South Africa (SA). While the initial introduction focused on issues such as the development and implementation of new guidelines, supply, and the development of demand creation strategies, the need to integrate PrEP services with sexual and reproductive health (SRH) services has gained traction both globally and locally. Project PrEP was implemented in eight healthcare facilities and four mobile clinics in three provinces in SA. Using monitoring data from across the four project clusters, and 4,949 clients, over a 21-month period, we conducted an analysis of baseline routine monitoring data to examine contraceptive uptake in adolescent girls and young women (AGYW) initiating PrEP at project sites. Two-thirds of women (62.3%, n = 3,083) reported the current use of contraception at baseline, with the most commonly used methods being hormonal injectables (61.9%, n = 1,829) and male condoms (19.4%, n = 575). A third (32.3%, n = 603) of the non-contraceptive users accepted a method at PrEP initiation. From a total of 1,007 (32.7%) current contraceptive users at baseline, 865 (85.9%) chose the same or a different method at this visit. The method uptake at PrEP initiation increased the overall contraceptive prevalence by 12.2 to 74.5%. Data indicated that over a third (38.8%, n = 725) who were not using a method at baseline described themselves as consistent condom users. Although a major focus of the project was on PrEP service provision, all women were counseled and offered contraceptive services. The acceptance of a method by a third of non-users was promising; however, more understanding of those who did not take up a method is required. The need to leverage opportunities for the promotion of the integration of HIV and family planning at all levels of PrEP provision was highlighted.

Impact of 2017 ACC/AHA guideline on prevalence, awareness, treatment, control, and determinants of hypertension: a population-based cross-sectional study in southwest of Iran

BackgroundIn 2017, the American College of Cardiology/American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention.MethodsThis population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire.ResultsAmong 30,506 participants, 30,424 individuals aged 20–65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45–54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively.ConclusionsIn the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline.

Admission avoidance in acute epistaxis: A prospective national audit during the initial peak of the COVID-19 pandemic.

To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Prospective multicentre national audit over 12weeks from 6th April 2020. UK secondary care ENT departments. Adult patients with acute epistaxis. Re-presentation within 10days for patients discharged from the ED. Eighty three centres from all four UK nations submitted 2631 valid cases. The majority of cases were ED referrals (89.7%, n=2358/2631). 54.6% were discharged from the ED following ENT review (n=1267/2322), of whom 19.5% re-presented within 10days (n=245/1259) and 6.8% were ultimately admitted (n=86/1259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n=1099/2355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n=332/1125), 18.2% re-presented (n=60/330); dissolvable products, 71.1% discharged (n=488/686), 21.8% re-presented (n=106/486); cautery only, 89.2% discharged (n=247/277), 20.0% re-presented (n=49/245); and no intranasal intervention, 85.5% discharged (n=200/234), 15.2% re-presented (n=30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10days. Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis.

Development of the teacher&amp;apos;s competence in the conditions of additional professional education

The article reveals the essence of the competency approach in the process of teachers’ qualification development. The specificity of additional professional education, its advantages in comparison with the basic training of a teacher at a university are characterized. The content of the concepts of &amp;quot;competence&amp;quot; and &amp;quot;professional competence&amp;quot; of a teacher in the innovative conditions of education development is presented, their scientific and theoretical justification is given based on the analysis of scientific and pedagogical sources. The main guidelines and pedagogical conditions of the process under study are identified; the new functions of the teacher in the aspect of the implementation of new guidelines in education are described. The necessity of updating the content and technology of the organization of the educational process within the framework of additional professional education organized on the basis of a higher educational institution is actualized. A description of the five-year work experience of the Ryazan State University named after S.A. Yesenin on the organization of advanced training of teachers in the competence paradigm in the city of Ryazan and the Ryazan region: the key objectives of the course training of teachers, the problematic thematic field of the programs of advanced training and retraining of teaching staff on popular topics are identified, the results of the experimental experience of the university on the development of the competence of certified teachers at the stage of postgraduate education are analyzed. In conclusion, the article substantiates the prospects for the teacher&amp;apos;s competence development: the development of the educational process and the quality of education.

Admission avoidance in tonsillitis and peritonsillar abscess: A prospective national audit during the initial peak of the COVID‐19 pandemic

ObjectivesTo report changes in practice brought about by COVID‐19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re‐presentations for patients discharged from the emergency department (ED).DesignProspective multicentre national audit over 12 weeks from 6 April 2020.SettingUK secondary care ENT departments.ParticipantsAdult patients with acute tonsillitis or PTA.Main outcome measuresRe‐presentation within 10 days for patients discharged from the ED.Results83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n = 410) of tonsillitis and 45.3% (187/413) of PTAs were discharged from ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re‐presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTAs.IV steroids and antibiotics increased the percentage of patients able to swallow from 35.8% to 72.5% for tonsillitis (n = 270/754 and 441/608) and from 22.3% to 71.0% for PTA (n = 92/413 and 265/373).77.2% of PTAs underwent drainage (n = 319/413), with no significant difference in re‐presentations in those drained vs not‐drained (10.6% vs 9.5%, n = 15/142 vs 4/42, P = .846).Univariable logistic regression showed no significant predictors of re‐presentation within 10 days.ConclusionsManagement of tonsillitis and PTA changed during the initial peak of the pandemic, shifting towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.

Impact of the implementation of new guidelines on the management of patients with HIV infection at an advanced HIV clinic in Kinshasa, Democratic Republic of Congo (DRC)

BackgroundHIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC).MethodsA retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/μl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%.ResultsTwo hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/μl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and toxoplasmosis were also much improved after the implementation of new guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new guidelines. Death odds after the implementation of new guidelines were significantly lower than before new guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05.ConclusionsSimplification and implementation of a new and improved HIV clinical guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.

COVID-19 in a community hospital

The rapid spread of COVID-19 across the globe quickly and drastically changed the way we practice medicine. In order to respond to its effects, careful planning and implementation of new guidelines and protocols was crucial to ensure the safety of both patients and staff. Given the limitations of space, staff, and resources in the community hospitals, a centralized command center, robust lines of communication within the department and between departments, and contingency and surge planning in this setting were critical. This chapter focuses on the unique challenges of practicing within a Level II hospital during a global pandemic.

Barriers to the implementation of new guidelines among pediatric surgeons: online survey.

To identify barriers that prevent pediatric surgeons from implementing updated practice guidelines. An online survey targeting pediatric surgeons was conducted on the StayCurrent MD Application (SCMA) and Pediatric Surgery Education Facebook page (PSE FBP). The survey results for pediatric surgeons of underdeveloped countries (PSUC) and pediatric surgeons of developed countries (PSDC) was compared and analyzed. Based on the number of active members on PSE FBP and SCA, the response rate was 32.3% (174/539), 66.3% of responses were from PSUC. The majority of PSUC (73%) wanted to have convincing guidelines and the plurality of PSDC (46%) wanted to see approval by the American Pediatric Surgical Association (APSA) for implementation of new guidelines. Lack of resources was the number one response (78%) for PSUC not implementing the most up to date guidelines and about 40% of the PSDC responded "concerned about malpractice liability." PSUC and PSDC identified very different barriers to implementation of new guidelines. It is reassuring that accessibility to treatment is not the primary issue, though resistance to implementation is a resounding concern. Identifying the barriers will highlight areas that need to be addressed, and awareness may help resolve some of the barriers.

Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers

BackgroundSyncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. MethodsMixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. ResultsAnalysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. ConclusionsDespite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.

Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research

BackgroundGuideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians’ perceptions of facilitators and barriers to the use of the IMPACT protocol.MethodsGuided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use.ResultsDomains most often reported as fundamental to the use of the IMPACT protocol included ‘social/professional role and identity’, ‘environmental context and resources’ and ‘social influences’. These factors seemingly influenced professional confidence, with participants noting ‘goals’ that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain ‘environmental context and resources’ also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education – both formal and informal.ConclusionsA range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.

Implementation of new guidelines in the prehospital services: a nationwide survey of Norway

BackgroundA debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process.MethodAn electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline.ResultsIn all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents.ConclusionAlthough the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline.

Improving neonatal resuscitation in Tennessee: a large-scale, quality improvement project.

We report a statewide collaborative quality initiative to improve resuscitation and stabilization practices following introduction of the 6th edition of the Neonatal Resuscitation Program. Participants drafted a consensus toolkit of interventions and corresponding measures. Hospital teams collected baseline data, and implemented changes using PDSA-cycles and statistical process control charts. Nine Tennessee NICUs submitted data on 3771 resuscitations. "Special cause" improvements were achieved and sustained for pre-resuscitation checklists (77-90%) and team briefings (80-92%). Time to intravenous access (50-42 min), glucose infusion initiation (73-60 min), and antibiotic dosing (113-98 min) were also significantly reduced. Teams were unable to meet new NRP oxygen saturation targets. Improvements in post-resuscitation debriefing were not sustained, while communication with parents declined significantly (68-60%). Large-scale collaboration facilitated statewide implementation of new guidelines, while highlighting under-appreciated systems challenges among competing resource demands.

Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain.

The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.