Multifaceted Implementation Strategy Research Articles

Towards a nationwide implementation of a standardized nutrition and dietetics terminology in clinical practice: a pre-implementation focus group study including a pretest and using the consolidated framework for implementation research

Background & AimsIn order to assure high quality of nutrition and dietetic care as well as research, the implementation of a standardized terminology, such as the World Health Organization (WHO) International Classification of Functioning, Disability and Health for Dietetics (ICF-Dietetics) is indispensable. The aim of this study was to explore the clinical practicability and applicability of the ICF-Dietetics in the field of nutrition and dietetic practice prior to the implementation in order to develop criteria (points to consider) for a targeted implementation strategy.MethodsA focus group study including a pretest of the ICF-Dietetics was conducted. Subsequently, facilitators and barriers for a nationwide implementation of the ICF-Dietetics in clinical nutrition and dietetic practice were identified and linked to interventions (combining theory-based and group-based approach) using the Consolidated Framework of Implementation Research (CFIR) to organize and represent data and summarized in a logic model.ResultsIn the pretest 55 clinical documentations which consisted of 248 different ICF-Dietetics categories were received. In four focus groups with 22 health professionals, 66 relevant higher-level themes and implementation strategy criteria (points to consider) were identified. These themes referred to all five domains of the CFIR, namely intervention characteristics, inner setting, outer setting, characteristics of individuals and implementation process and contained important barriers and facilitators that were linked to six implementation objectives as well as six context requirements and five main actors.ConclusionsThis study provides facilitators and barriers to be addressed when implementing the ICF-Dietetics in clinical practice and shows potential interventions based on this analysis. A nationwide implementation was mainly seen as a great advantage for enhancing quality and continuity of care and for providing comparable data. However, it requires further refinements and a multifaceted implementation strategy where the engagement of leadership of institutions plays a crucial role. These results have provided a foundation for a targeted implementation strategy to increase the success, reproducibility and comparability.

State Leadership in U.S. Climate Change and Energy Policy: The California Experience

It is a long-held belief among scholars and practitioners that the State of California is a notable subnational leader in environmental and climate change policy. This article focuses primarily on four essential contextual factors that explain why and how within the United States’ federal system of government California has become such an important leader, performing far in excess of the national government and most other states. These essential factors are preferences, authority, capacity, and effectiveness. The article then moves to the multifaceted implementation strategy California policy makers have employed to realize their environmental goals. Finally, despite the history of strong leadership, the state continues to face a host of significant challenges in realizing its ambitious climate change goals for the coming decades.

Medication review service implementation in community pharmacy settings: Scoping review with focus on implementation studies.

Medication reviews are a structured clinical intervention with the general goals of improving patient drug knowledge and detecting and resolving drug-related problems in an individual patient's medication regimen. A variety of barriers entrenched in the traditional drug distribution and dispensing model of pharmacy business has continued to challenge the implementation efforts of medication review services worldwide in the community pharmacy setting. MAIN OBJECTIVES: i) Characterize original research studies that sought to enhance medication review service implementation in community pharmacy settings. ii) Categorize the broader corpus of scientific literature (beyond original implementation studies) on medication review service implementation in community pharmacy settings. A broad systematic search strategy was applied to ovid MEDLINE, Embase, CINAHL and Cochrane Library to create an over-arching view and extensively ordered bibliography of the diverse research publication types dealing with the topic of medication review service implementation in the community pharmacy setting. A scoping review was subsequently conducted on original research studies that utilized various strategies to enhance the implementation of this service in community pharmacies. Data-charting evaluated the location of implementation studies, the strategies undertaken, the scale of implementation strategies, the use of DII (Dissemination, Implementation and Improvement) science theory, sample sizes, and DII outcomes. Of 5947 records screened, 419 fulfilled the inclusion criteria (from abstract screening) to be deemed suitable for categorization and inclusion into the broader survey on this topic. Of these 419 publications, only 75 were original research specifically focused on enhancing the implementation of medication reviews in community pharmacy. A large majority of the publications were qualitative studies (n = 203). The remaining articles were improvement studies (n = 36), descriptive observational studies (n = 49), reviews (n = 69) and methodology papers (n = 16). Twenty-nine of these articles were deemed suitable for inclusion in more than one category. After full-text screening, 41 of the 75 implementation publications, representing 40 original studies, published between 1999 and 2019, were eligible for data-charting. The majority of these studies occurred in North America (n = 30), used some form of education as the most common implementation strategy (n = 22) and measured 'adoption' (extent or frequency of medication reviews delivered) most frequently as an implementation outcome (n = 30). Just over half of the studies used a multi-faceted implementation strategy (n = 21). Only 9 studies used a theory, model or framework at any point in the research process to test hypotheses or explain empirical findings. There is an abundance of publications addressing various issues surrounding medication review implementation in community pharmacies. However, the literature appears disproportionately represented by qualitative studies. There is also a need for more rigorously conducted implementation studies on medication review services in community pharmacy.

Implementation Strategies to Improve Evidence-Based Bathing Practices in a Neuro ICU.

Evidence supports daily bathing using chlorhexidine gluconate (CHG) cloths to decrease preventable hospital-acquired central line-associated bloodstream infections (CLABSIs). However, implementation of this practice is inconsistent. Using multifaceted strategies to promote implementation is supported in the literature, yet there is a gap in knowing which strategies are most successful. Using the Grol and Wensing Model of Implementation as a guide, the purpose of this study was to determine whether using tailored, multifaceted strategies would improve implementation of daily CHG bathing and decrease CLABSIs in a large neuro ICU. An observational pre-/postdesign was used. Following implementation, infection rates decreased (P = .031). Statistically significant improvements were also seen across all process measures: bathing documentation, nursing knowledge, and perceived importance of CHG bathing. This study assists in closing the research-practice gap by using tailored, multifaceted implementation strategies to increase use of evidence-based nursing care for infection prevention practices.

Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol

BackgroundAlignment across levels of leadership within an organization is needed for successful implementation of evidence-based practice. The leadership and organizational change for implementation (LOCI) intervention is a multi-faceted multilevel implementation strategy focusing on enhancing first-level general and implementation leadership while also engaging with organization upper management to develop an organizational climate for implementation. The aim of the project is to evaluate the effectiveness of LOCI in supporting the implementation of evidence-based treatment for PTSD in child- and adult-specialized mental health clinics in health trusts in Norway.MethodsThe study design is a stepped-wedge cluster randomized trial with enrollment of clinics in three cohorts. Executives, clinic leaders, and therapists will be asked to complete surveys assessing leadership and implementation climate. Surveys will be completed at baseline, 4, 8, 12, 16, and 20 months. Results from surveys will be shared with executives and clinic leaders to inform the subsequent creation of tailored leadership and climate development plans for enhanced implementation. Patients will complete surveys measuring traumatic events and post-traumatic stress symptoms during the therapy process. Therapy sessions will be audio or video recorded and scored for fidelity as part of training.DiscussionThis study aims to provide knowledge on how to improve leadership and organizational climate to enhance effective implementation of evidence-based treatments in mental health services.Trial registrationThe study has been registrated in ClinicalTrials with ID NCT03719651.

A Novel Clinical Decision Support System for Gastrointestinal Bleeding Risk Stratification in the Critically Ill

Acid suppression therapy can reduce the development of stress and medication-related mucosal disease when prescribed appropriately. Suboptimal inpatient prescribing of acid suppression therapy therefore may lead to increased development of gastrointestinal hemorrhage in high-risk populations. The aim of this quality improvement study was to improve appropriate acid suppression therapy in patients admitted to ICUs in an academic medical center. An adaptable, multifaceted implementation strategy guided by unit-based root cause analysis was initially developed in a single ICU with a high-risk population. Identifiable targets of intervention, including provider awareness, unstructured rounding protocols, and electronic communication tools, were augmented by the development of an automated alert system. This electronic dashboard risk-stratified patients based on information derived from the electronic medical record (EMR). The dashboard then offered clinical decision support. Use of the dashboard and percentage of appropriate acid suppression therapy prescriptions were tracked over time. Appropriate acid suppression therapy prescribing was improved from 72.9% to 86.0% (p < 0.001). Automated technology including an EMR-supported electronic dashboard was the foundation of successful intervention. Considering the deleterious effects of both under- and overprescribing of acid suppression therapy, particularly in high-risk patient populations, this type of technology may lead to enhanced patient outcomes.

Implementation strategies to reduce surgical site infections: A systematic review

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence. To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs. Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate). In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers. Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

A pragmatic cluster randomised controlled trial of a tailored intervention to improve the initial management of suspected encephalitis.

ObjectiveTo determine whether a tailored multifaceted implementation strategy improves the initial management of patients with suspected encephalitis.DesignPragmatic two arm cluster randomised controlled trial.SettingHospitals within the United Kingdom.ParticipantsTwenty-four hospitals nested within 12 postgraduate deaneries. Patients were identified retrospectively by searching discharge, microbiology, radiology and pharmacy records and included if they met clinical criteria or had a recorded suspicion of encephalitis.InterventionAn implementation strategy designed to overcome barriers to change, comprising local action planning, education and training, feedback on performance, a lumbar puncture pack and a range of optional components.OutcomesThe primary outcome was the proportion of patients with suspected encephalitis undergoing diagnostic lumbar puncture within 12 hours of admission and starting aciclovir treatment within six hours. Secondary outcomes included the proportions of adults and children who had a lumbar puncture, who had appropriate cerebrospinal fluid investigations, and who had appropriate radiological imaging within 24 hours of admission. Data were collected from patient records for 12 months before and 12 months during the intervention period, and analysed blind to allocation.Results13 hospitals were randomised to intervention and 11 to control (no intervention), with 266 and 223 patients with suspected encephalitis identified respectively. There was no significant difference in primary outcome between intervention and control hospitals (13.5% and 14.8% respectively, p = 0.619; treatment effect -0.188, 95% confidence interval -0.927 to 0.552), but both had improved compared to pre-intervention (8.5%).ConclusionThe improvement in both intervention and control arms may reflect overall progress in management of encephalitis through wider awareness and education.Trial registrationControlled Trials: ISRCTN06886935.

Cultivating healing by implementing restorative practices for youth: Protocol for a cluster randomized trial

Restorative practices, non-punitive approaches to discipline focused on developing relationships and healing harm, have emerged as an alternative to exclusionary disciplinary actions, such as suspensions and expulsions. Despite widespread interest in restorative practices, there is little empirical research regarding their effectiveness. This cluster randomized controlled trial of 12 culturally-diverse U.S. middle schools will examine whether using restorative practices with a multi-faceted implementation strategy (a) reduces negative outcomes, including expulsions, suspensions, truancy, and bullying and (b) improves positive outcomes related to grade-point-average, sense of safety, and teacher support. Secondary goals are to identify factors associated with implementation success and conduct a cost-benefit analysis examining return on investment from societal and government perspectives. A mixed-methods research design is employed to address study aims.

Agents of change: establishing quality improvement collaboratives to improve adherence to Australian clinical guidelines for dementia care

BackgroundDissemination of clinical practice guidelines alone is insufficient to create meaningful change in clinical practice. Quality improvement collaborative models have potential to address the evidence-practice gap in dementia care because they capitalise on known knowledge translation enablers and incorporate optimal approaches to implementation. Non-pharmacological interventions focused on promoting independence are effective and favoured by people with dementia and their carers but are not routinely implemented. The objective of this translational project is to assess the impact of quality improvement collaboratives (QICs) on adherence to non-pharmacological recommendations from the Clinical Practice Guidelines for Dementia in Australia.MethodsThis project will employ an interrupted time-series design with process evaluation to assess the impact, uptake, feasibility, accessibility, cost, and sustainability of the QICs over 18 months. Thirty clinicians from across Australia will be invited to join the QICs to build their capacity in leading innovation in dementia care. Clinicians will participate in a training program and be supported to develop and implement a quality improvement project unique to their service context using plan-do-study-act cycles. Regular online meetings with their peers in the QIC will facilitate benchmarking and problem-solving. Clinicians will describe their practice via monthly checklists, and guideline adherence will be determined against a set of defined criteria. Phone interviews with up to 180 client dyads will be used to assess satisfaction with care and client outcomes. Clinician interviews and field note data will be used to explore implementation and costs. Involvement of people with dementia and carers will be embedded in the study design, conduct, and reporting, in addition to clinical and industry expertise.DiscussionThe quality of dementia care in Australia is largely dependent on the clinician involved and the extent to which they apply best available evidence in their practice. This study will determine the elements of this multifaceted implementation strategy that contributed to guideline adherence and client outcomes. The findings will inform future translational approaches to improving care and outcomes for people with dementia and their carers.Trial registrationRegistered with the Australian New Zealand Clinical Trials Registry 21 February 2018 (ACTRN12618000268246).

Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study

ObjectiveDespite a high number of the internationally produced and implemented clinical guidelines, the adherence with them is still low in healthcare. This study aimed at exploring the perspectives and experiences...

Implementation of Arkansas’s Initiative to Reduce Suspension and Expulsion of Young Children

This article describes the development, initial implementation, and formative evaluation of Arkansas’s plan to reduce suspensions and expulsion from early care and education (ECE) settings. We describe how Arkansas used multifaceted implementation strategies to facilitate change in six areas: policy, workforce development, specialized supports, family partnerships, child screening, and data tracking. We also highlight key findings from the formative evaluation. For example, needs assessment data revealed that 40.8% of ECE providers suspended at least one child in the past year, and 9% expelled one or more children. We evaluated efforts to educate ECE providers on new nonexpulsion policies and new supports, and results indicate that 89.5% of directors agreed that they understand why young children should not be suspended or expelled, though the majority reported concern about implementing a nonexpulsion policy. Initial utilization data from a new ECE provider support system indicate that in the first quarter, 53 requests were submitted for help with challenging classroom behavior. Most requests involved male children over the age of 3, and one-third of the requests referenced traumatic events experienced by the children.

Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial

BackgroundPay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs).MethodsBuilding on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes.ResultsAt trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191–$16,171).ConclusionThis study provides experimental evidence supporting P4P as a cost-effective implementation strategy.Trial registrationNCT01016704.

A Multi-Faceted Implementation Strategy to Improve Acid Suppression Prophylaxis Among Patients Admitted to the Cardiac Intensive Care Unit: Results of a Longitudinal Study

Acid suppressive therapy (AST) can reduce the development of stress and medication-related mucosal disease when prescribed appropriately. Previous data by our group show suboptimal prescribing of AST in the hospital among cardiac patients. The aim of this quality improvement study was to improve appropriate AST in patients admitted to the cardiac intensive care unit (CCU) of a quaternary care hospital. An AST guideline was first established through collaboration among cardiology, gastroenterology, and pharmacy divisions based on the following risk factors: intubation, organic coagulopathy, use of anticoagulant and antiplatelet agents, and use of high-dose steroids (Figure 1). A retrospective chart review of all patients admitted to the CCU from September 1, 2016 to January 4, 2017 was performed to identify the percentage of patients on appropriate AST based on this guideline. A root-cause analysis was then performed identifying the following targets for intervention: provider awareness, unstructured rounding protocols, and lack of an automated alert system. A stepwise implementation strategy was developed targeting these factors, which was rolled out in 4 Plan-Do-Study-Act (PDSA) cycles. Data on AST were prospectively collected from the date of the first intervention on December 15, 2017 through August 31, 2017. These data were then analyzed to determine rates of appropriate AST pre- and post-intervention. During the pre-intervention phase, 264 patients were admitted to the CCU, of which only 72.9% were prescribed appropriate AST. After the first PDSA cycle, which included development and dissemination of an evidence-based AST guideline, 102 patients were admitted, 81.1% of which had appropriate AST. After the second PDSA cycle, which focused on structuring morning rounds to include AST discussion, compliance rates improved to 84.0% of 31 patients. The third PDSA cycle included incorporation of an electronic automated high-risk patient tracker, which increased appropriate AST to 86.1% of 428 patients (Figure 2). These results were sustained through the duration of the study. Through a multi-faceted implementation strategy that included development of guidelines, a new rounding structure, and an electronic dashboard to highlight opportunities for intervention, our group increased appropriate AST from 72.9% to 86.1% of all patients admitted to our hospital’s CCU. Considering the deleterious effects of both under- and overprescribing of AST, particularly in high-risk patient populations, such as those with cardiac disease who are critically ill, this improvement may lead to enhanced patient outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Effectiveness of a multifaceted implementation strategy compared to usual care on low back pain guideline adherence among general practitioners

BackgroundTo improve patient care, and to reduce unnecessary referrals for diagnostic imaging and medical specialist care for low back pain, an evidence-based guideline for low back pain was developed in the Netherlands in 2010. The current study evaluated the effect of a multifaceted implementation strategy on guideline adherence among Dutch general practitioners.MethodsThe implementation strategy included a multidisciplinary training, provision of educational material and an interactive website for healthcare professionals, supported by a multimedia eHealth intervention for patients with low back pain. Adherence was measured using performance indicators based on 3 months data extracted from the contacts with patients with low back pain recorded in the electronic medical records of participating general practitioners. Performance indicators were compared between two groups: a usual care group and an implementation group. Performance indicators were referrals to consultations with medical specialists, to diagnostic imaging, and to psychosocial and/or occupational physician consultations, and inquiries about psychosocial and occupational risk factors.ResultsThe electronic medical records of 5130 patient contacts for LBP were analysed; 2453 patient contacts in the usual care group and 2677 patient contacts in the implementation group. Overall, rates of referral and of recorded inquiries regarding psychosocial and occupational risk factors remained low in both groups over time. The only statistically significant difference found was a reduction in the number of referrals to neurologists in the implementation group (from 100 (7%) to 50 (4%)) compared to the usual care group (from 48 (4%) to 50 (4%), (p < 0.01)). There were no other between-group differences in referrals.ConclusionIn the short term, the strategy did not result in improved guideline adherence among general practitioners, and it is not recommended for widespread use. However, baseline referral rates in participating practices were already low, possibly leaving only little room for improvement. Inquiries for psychosocial and occupational risk factors remained low and this leaves room for improvement.Trial registrationThis trial is registered in the Netherlands Trial Register (NTR): NTR4329. Registration date: December 20th, 2013.

689 - A Multi-Faceted Implementation Strategy to Improve Acid Suppression Prophylaxis Among Patients Admitted to the Cardiac Intensive Care Unit: Results of a Longitudinal Study

689 - A Multi-Faceted Implementation Strategy to Improve Acid Suppression Prophylaxis Among Patients Admitted to the Cardiac Intensive Care Unit: Results of a Longitudinal Study

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

BackgroundExternal change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.MethodsWe searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.ResultsAcademic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.ConclusionsOur results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

Study of Awareness and Performance of Ahvazi Midwives about Physiologic Childbirth in Public Hospitals, 2016

Abstract Introduction: To promote normal childbirth the care during childbirth should be on evidence-based care. Evidence-based care practices promote physiological birth and midwives. This study studied midwives’ awareness and performance about physiological childbirth in Ahvaz publiv maternity services. Methods: This descriptive study was conducted on maternity units in which 128 midwives were recruited using census sampling. The researcher made questionnaire were used for self-reporting of awareness and performance of midwives. Results: Majority of midwives (86.7%) had Bachelor degree, had (1-7) year’s work experience (64.1) . This study showed that the Ahvazi midwives had relatively good awareness of physiologic labour items however the performance of them was not as ideal as their awareness. Conclusions: Iranian midwives are informed about evidence-based practice in childbirth which indicates that attempts to promote physiologic childbirth has been useful, however multifaceted implementation strategies are necessary to promote the use of evidence-based practice in clinical practice and health care decision making during labour childbirth.

Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation

ObjectiveTo evaluate the implementation and effectiveness of an internet-based perioperative care programme for patients following gynaecological surgery for benign disease.DesignStepped-wedge cluster randomised controlled trial.SettingSecondary care, nine hospitals in the Netherlands,...

Increasing compliance with a clinical practice guideline for fetal fibronectin testing and the management of threatened preterm labour: A quality improvement project

ObjectiveTo increase adherence to a local hospital clinical practice guideline for the use of fetal fibronectin testing in women presenting with symptoms of threatened preterm labour. Study designA quality improvement project using a multi-faceted implementation strategy. SettingNational Women’s Health, Auckland City Hospital; a tertiary referral maternity unit in Auckland, New Zealand. PopulationAll obstetricians, junior obstetric doctors and hospital employed midwives. MethodsA pre-education audit and survey, compulsory interactive educational intervention with audit feedback and provision of reminders followed by a post-education audit and survey one year later. Main outcome measuresNumber of fetal fibronectin tests performed, proportion of tests performed meeting clinical criteria for testing and proportion of results managed according to hospital guideline. ResultsThere was a 25% increase in the number of tests performed with an increase in the proportion that met clinical criteria for testing, 76% (31/41)–93% (51/55) (OR 4.1, 95% CI 1.2–14.2). Adherence to guidelines for clinical management according to fFN results changed over time, 80% (33/41)–95% (52/55) (OR 4.2, 95% CI 1.04–17.0). Clinician knowledge on some (but not all) indications for fFN testing improved. Education and reminders did not improve understanding of clinical scenarios that may result in a false positive fFN test. ConclusionsA multi-faceted approach of audit and clinician feedback, interactive education and reminders supports the implementation of a clinical practice guideline for the use of fFN as a preterm birth prediction test for women presenting with symptoms of threatened preterm labour.