Potential Implementation Strategies Research Articles

Factors affecting speech pathologists’ implementation of stroke management guidelines: a thematic analysis

Purpose: Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be underutilised. There is limited research into the reasons for this, especially in speech pathology. This study provides the first in-depth, qualitative examination of the barriers and facilitators that speech pathologists perceive and experience when implementing guidelines. Methods: A maximum variation sample of eight speech pathologists participated in a semi-structured interview concerning the implementation of the National Stroke Foundation's Clinical Guidelines for Stroke Management 2010. Interviews were transcribed, thematically analysed and member checked before overall themes were identified. Results: Three main themes and ten subthemes were identified. The first main theme, making implementation explicit, reflected the necessity of accessing and understanding guideline recommendations, and focussing specifically on implementation in context. In the second theme, demand versus ability to change, the size of changes required was compared with available resources and collaboration. The final theme, Speech pathologist motivation to implement guidelines, demonstrated the influence of individual perception of the guidelines and personal commitment to improved practice. Conclusions: Factors affecting implementation are complex, and are not exclusively barriers or facilitators. Some potential implementation strategies are suggested. Further research is recommended.Implications for RehabilitationIn most Western nations, stroke remains the single greatest cause of disability, including communication and swallowing disabilities.Although adherence to stroke clinical practice guidelines improves stroke patient outcomes, guidelines continue to be underutilised, and the reasons for this are not well understood.This is the first in-depth qualitative study identifying the complex barriers and facilitators to guideline implementation as experienced by speech pathologists in stroke care.Suggested implementation strategies include local monitoring of guideline implementation (e.g. team meetings, audits), increasing collaboration on implementation projects (e.g. managerial involvement, networking), and seeking speech pathologist input into guideline development.

Meeting Mandatory Infectious Disease Reporting Requirements: The Department of Veterans Affairs' Plan

In response to pending legislation, the Department of Veterans Affairs (VA) recently issued a new Directive that requires mandatory reporting of infectious diseases to public health authorities. One potential implementation strategy is to use the VA's Healthcare Acquired Infection and Influenza Surveillance System - an electronic biosurveillance system that will soon be released nationally - which would not only build on existing technology, optimize reporting, and minimize work burdens on VA staff but also allow the VA to comply with Meaningful Use requirements.

Design Considerations and Ring-down Characteristics of Micromachined, High Current Density Capacitors

The need for integrated passive components which meet the stringent power system requirements imposed by increased data rates, signal path density and challenging power distribution network topologies in integrated systems yield diverse motivations for high density, miniaturized capacitors capable of quickly sourcing large quantities of current. These diverse motivations have led to the realization of high density capacitor structures through the means of several technologies. These structures have been evaluated as high-speed, energy storage devices and their respective fabrication technologies have been closely compared for matching integrated circuit speed and density increase, chip current requirements, low resistance, low leakage current, high capacitance and compatibility with relatively high frequencies of operation (~1GHz). These technologies include devices that utilize pn junctions, Schottky barriers, optimized surface area techniques and the utilization of high dielectric constant (high-K) materials, such as hafnium oxide, as a dielectric layer through the means of atomic layer deposition (ALD). The resulting devices were micro-machined, large surface area, thin, high-density capacitor technologies optimized as embedded passive devices for thin silicon interposers. This work outlines the design, fabrication, simulation and testing of each device revision using standard silicon microfabrication processes and silicon interposer technologies. Consequently, capacitive storage devices were micro-machined with geometries which maximize surface area and exhibit the capability of sourcing 100A of current with a response time greater than 100 A/nsec through the use of thin layered, ALD high-K materials. The simulation and testing of these devices show general agreement when subjected to a standard ring-down procedure. This paper provides descriptions and design challenges encountered during fabrication, testing and integration of these passive devices. In addition, potential device integration and implementation strategies for use in silicon interposers are also provided. The modification and revision of several device generations is documented showing increased device capacitance density, maximized current capabilities and minimized effects of series inductance and resistance. The resulting structures are thin, capacitive devices that may be micro-machined using industry standard Si MEMS processes and are compatible with Si interposer 3D technologies. The subsequent design processes allow integrated passive components to be attached beneath chips in order to maximize system area and minimize the chip real estate required for capacitive energy storage devices.

Decision-making styles of seriously ill male Veterans for end-of-life care: Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders

ObjectiveTo describe self-reported decision-making styles and associated pathways through end-of-life (EOL) decision-making for African-American, Caucasian, and Hispanic seriously ill male Veterans, and to examine potential relationships of race/ethnicity on these styles. MethodsForty-four African American, White, and Hispanic male Veterans with advanced serious illnesses participated in 8 racially/ethnically homogenous focus groups. Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the racial/ethnic groups. ResultsPatients described two main decision-making styles, deciding for oneself and letting others decide, leading to five variants that we labeled Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders. These variants, with exception of avoiders (not found among White patients), were found across all racial/ethnic groups. The variants suggested different ‘implementation strategies’, i.e., how clear patients made decisions and whether or not they then effectively communicated them. ConclusionThese identified decision-making styles and variants generate strategies for clinicians to better address individualized advance care planning. Practice implicationsPhysicians should elicit seriously ill patients’ decision-making styles and consider potential implementation strategies these styles may generate, thus tailoring individualized recommendations to assist patients in their advance care planning. Patient-centered EOL decision-making can ensure that patient preferences are upheld.

Mapping Topics for Program Enhancement in Undergraduate Process Engineering Education

Identifying recurring themes and creating a topics map provides a useful tool for program enhancement. Topic maps can be used to streamline teaching and create opportunities for introducing supplementary topics. It encourages consistency and continuity within a program and opens dialogue among faculty members. It gives students context for their current learning within the overall program picture. This 2 Results and Discussion on Mapping paper examines how the Discipline of Process Engineering at Memorial University collectively examined their program, identified seven common themes and mapped their evolution through the program. The outcomes of this examination will be presented and potential implementation strategies to further enhance the program and assist student learning will be discussed.

Implementation of the chemistry module MECCA (v2.5) in the modal aerosol version of the Community Atmosphere Model component (v3.6.33) of the Community Earth System Model

Abstract. A coupled atmospheric chemistry and climate system model was developed using the modal aerosol version of the National Center for Atmospheric Research Community Atmosphere Model (modal-CAM; v3.6.33) and the Max Planck Institute for Chemistry's Module Efficiently Calculating the Chemistry of the Atmosphere (MECCA; v2.5) to provide enhanced resolution of multiphase processes, particularly those involving inorganic halogens, and associated impacts on atmospheric composition and climate. Three Rosenbrock solvers (Ros-2, Ros-3, RODAS-3) were tested in conjunction with the basic load-balancing options available to modal-CAM (1) to establish an optimal configuration of the implicitly-solved multiphase chemistry module that maximizes both computational speed and repeatability of Ros-2 and RODAS-3 results versus Ros-3, and (2) to identify potential implementation strategies for future versions of this and similar coupled systems. RODAS-3 was faster than Ros-2 and Ros-3 with good reproduction of Ros-3 results, while Ros-2 was both slower and substantially less reproducible relative to Ros-3 results. Modal-CAM with MECCA chemistry was a factor of 15 slower than modal-CAM using standard chemistry. MECCA chemistry integration times demonstrated a systematic frequency distribution for all three solvers, and revealed that the change in run-time performance was due to a change in the frequency distribution of chemical integration times; the peak frequency was similar for all solvers. This suggests that efficient chemistry-focused load-balancing schemes can be developed that rely on the parameters of this frequency distribution.

Design, Simulation and Testing of High Density, High Current Micro-machined Embedded Capacitors

Due to increasing speed, density and number of signal paths in integrated circuits, motivations for high density capacitors capable of quickly sourcing large amounts of current have led to many design and fabrication investigations. This work outlines continued efforts to achieve devices which meet these stringent requirements and are compatible with standard silicon fabrication processes as well as silicon interposer technologies. Previous work has been further developed resulting in devices exhibiting greater capacitance values by employing geometries which maximize surface area. The Atomic Layer Deposition (ALD) of thin layered high K materials, such as Hafnium Oxide, as opposed to previous silicon-dioxide based devices effectively increased the capacitance per unit area of the structures. This paper outlines the design, fabrication, and testing of high density micro-machined embedded capacitors capable of quickly sourcing (i.e. risetimes greater than 100A/nsec) high currents (i.e. greater than 100A). These devices were successfully simulated then tested using a standard ringdown procedure. Generally, the resulting device characterization found during testing stages strongly correlates to the expected simulated device behavior. Subsequent descriptions and design challenges encountered during fabrication, testing and integration of these passive devices are outlined, as well as potential device integration and implementation strategies for use in silicon interposers. The modification and revision of several device generations is documented and presented. Increased device capacitive density, maximized current capabilities and minimized effects of series inductance and resistance are presented. These resulting thin, capacitive structures exhibit compatibility with Si interposer technology.

Implementing screening for Lynch syndrome among patients with newly diagnosed colorectal cancer: summary of a public health/clinical collaborative meeting

Lynch syndrome is the most common cause of inherited colorectal cancer, accounting for approximately 3% of all colorectal cancer cases in the United States. In 2009, an evidence-based review process conducted by the independent Evaluation of Genomic Applications in Practice and Prevention Working Group resulted in a recommendation to offer genetic testing for Lynch syndrome to all individuals with newly diagnosed colorectal cancer, with the intent of reducing morbidity and mortality in family members. To explore issues surrounding implementation of this recommendation, the Centers for Disease Control and Prevention convened a multidisciplinary working group meeting in September 2010. This article reviews background information regarding screening for Lynch syndrome and summarizes existing clinical paradigms, potential implementation strategies, and conclusions which emerged from the meeting. It was recognized that widespread implementation will present substantial challenges, and additional data from pilot studies will be needed. However, evidence of feasibility and population health benefits and the advantages of considering a public health approach were acknowledged. Lynch syndrome can potentially serve as a model to facilitate the development and implementation of population-level programs for evidence-based genomic medicine applications involving follow-up testing of at-risk relatives. Such endeavors will require multilevel and multidisciplinary approaches building on collaborative public health and clinical partnerships.Genet Med 2012:14(1):152–162

The Welfare Quality® project and beyond: Safeguarding farm animal well-being

Welfare Quality® was the largest ever European research project on animal welfare. Here, we briefly describe some major achievements of Welfare Quality® and identify future research priorities, potential strategies and organisational structures to build on the outcomes. Achievements include: definition of principles and criteria of good welfare; development of standardised, primarily animal-based measures for each welfare criterion and their integration in an overall assessment model. Since Welfare Quality® could not answer all the questions we recommend: 1. Continued development and refinement of the assessment systems and extension to new species. 2. The development of automatic measures of welfare to reduce the duration of the assessment while still retaining its holistic nature. 3. Exploration of potential implementation strategies across food chain actors. 4. Establishment of an independent body to manage and update the assessment and information systems, support their implementation and inform and engage stakeholders.

TSDS: high-performance merge, subset, and filter software for time series-like data

Time Series Data Server (TSDS) is a software package for implementing a server that provides fast super-setting, sub-setting, filtering, and uniform gridding of time series-like data. TSDS was developed to respond quickly to requests for long time spans of data. Data may be served from a fast database, typically created by aggregating granules (e.g., data files) from a remote data source and storing them in a local cache that is optimized for serving time series. The system was designed specifically for time series data, and is optimized for requests where the longest dimension of the requested data structure is time. Scalar, vector, and spectrogram time series types are supported. The user can interact with the server by requesting a time series, a date range, and an optional filter to apply to the data. Available filters include strides, block average/minimum/maximum, exclude, and inequality. Constraint expressions are supported, which allow such operations as a request for data from one time series when a different time series satisfied a specified relationship. TSDS builds upon DAP (Data Access Protocol), NcML (netCDF Mark-up language) and related software libraries. In this work, we describe the current design of this server, as well as planned features and potential implementation strategies.

Planning for pre‐exposure prophylaxis to prevent HIV transmission: challenges and opportunities

There are currently several ongoing or planned trials evaluating the efficacy of pre-exposure prophylaxis (PrEP) as a preventative approach to reducing the transmission of HIV. PrEP may prove ineffective, demonstrate partial efficacy, or show high efficacy and have the potential to reduce HIV infection in a significant way. However, in addition to the trial results, it is important that issues related to delivery, implementation and further research are also discussed. As a part of the ongoing discussion, in June 2009, the Bill & Melinda Gates Foundation sponsored a Planning for PrEP conference with stakeholders to review expected trial results, outline responsible educational approaches, and develop potential delivery and implementation strategies. The conference reinforced the need for continued and sustained dialogue to identify where PrEP implementation may fit best within an integrated HIV prevention package. This paper identifies the key action points that emerged from the Planning for PrEP meeting.

Physician attitudes toward regionalization of adult critical care: A national survey*

Regionalization has been proposed as a method to improve outcomes for patients with critical illness. We sought to determine intensivist physician attitudes and potential barriers to the regionalization of adult critical care. Mail survey. United States. Actively practicing physicians specializing in adult critical care, emergency medicine, or internal medicine listed in the 2008 American Medical Association Physician Masterfile (n = 1200). None. There were 569 eligible respondents (effective response rate = 53.0%). Respondents were similar to nonrespondents. Fifty-nine percent of respondents thought their hospital would mainly receive patients under a regionalized system, and 30% thought their hospital would mainly send patients. Opinions were split about whether regionalization would improve overall patient survival (52% agreed) and healthcare efficiency (66% agreed). Specialists in anesthesiology and surgery-critical care, academic physicians, and physicians who perceived that they would mainly receive patients were more likely to believe that regionalization would improve outcomes and efficiency (p < 0.001). The most commonly endorsed barriers to regionalization were personal strain on patient's families (66% agreed), current lack of a strong central authority (64% agreed), and the potential to overwhelm capacity at large hospitals (55% agreed). Commonly endorsed strategies to implement regionalization included using objective criteria to determine eligibility for transfer (87% agreed), developing common information technology platforms across hospitals (86% agreed), and demonstrating in a clinical trial that regionalization is beneficial (81% agreed). Intensivist physicians have mixed opinions about regionalization, with little consensus about whether regionalization will improve outcomes. Most felt that regionalization will improve patient outcomes, but many expressed concerns about unintended adverse consequences. Respondents identified several barriers and potential implementation strategies that can help policymakers design a regionalized system of critical care in the United States.

Upgrading Coal Using a Pneumatic Density-Based Separator

The potential of dry cleaning coal of varying ranks using a pneumatic table concentrator has been evaluated as part of an ongoing investigation. The evaluation has been performed at several sites throughout the United States where coal is extracted from surface open cast, highwall and underground operations as well as from coarse reject. The treated coals varied in feed ash content (i.e., 7–70%). Regardless of the mineral matter type, pure rock removal into the reject stream was achieved in all applications with little coal loss. Field data obtained when treating 50 × 6 mm run-of-mine bituminous coal indicate that 70–90% of the >2.0 Relative Density (RD) rock can be rejected. As a result, a clean product having acceptable market quality was generated from several coal sources including lignite, sub-bituminous, and bituminous coals. This article provides an overview of data from recent field testing of the dry air table technology and discusses the potential implementation strategy for the various sites evaluated.

A bioseparation process for removing heavy metals from waste water using biosorbents

The removal of heavy metals from our environment especially wastewater is now shifting from the use of conventional adsorbents to the use of biosorbents. The presence of heavy metals in the environment is of major concern because of their toxicity, bioaccumulating tendency, and threat to human life and the environment. In recent years, many low cost sorbents such as algae, fungi bacteria and lignocellulosic agricultural by-products have been investigated for their biosorption capacity towards heavy metals. In this comprehensive review, the emphasis is on outlining the occurrences and toxicology of heavy metals and the biosorption capacity of biosorbents compared to conventional adsorbents. A detailed description of the adsorption properties and mode of action of these biosorbents is offered in order to explain the heavy metal selectivity displayed by these biosorbents. The role of cell structure, cell wall, micropores and macropores is evaluated in terms of the potential of these biosorbents for metal sequestration. Binding mechanisms are discussed, including the key functional groups involved and the ion-exchange process. Quantification of metal-biomass interactions is fundamental to the evaluation of potential implementation strategies, hence, sorption isotherms, sorption kinetics, intraparticle diffusivities as well as models used to characterize biosorbent sorption are reviewed. The sorption behavior of some biosorbents with various heavy metals is summarized, their relative performance evaluated and a bioseperation process flow diagram for heavy metal removal from wastewater using biosorbents was proposed.

Report from a symposium on dissemination of evidence-based cancer prevention programs (United States)

While many cancer-prevention interventions aimed at behavioral change and risk reduction have proven successful in the research setting, few have been disseminated into the broader community and implemented on a wider scale. To date, research that has tested methods for disseminating effective intervention models has been sparse [1, 2]. With the goal of better understanding the dissemination process, including the identification of key knowledge gap areas and of potential implementation strategies for dissemination, the Harvard Center for Cancer Prevention and the Health Communication Core and Risk Reduction Program of the Dana-Farber/ Harvard Cancer Center co-sponsored a workshop on 12 April 2002, entitled "Dissemination of Evidence-based Cancer Prevention Programs."

Local impact of the NHMRC early breast cancer guidelines: where to from here?

To determine clinicians' recall of the National Health and Medical Research Council's (NHMRC) Clinical practice guidelines for the management of early breast cancer six months after publication, and their reactions to its content and potential dissemination and implementation strategies. Greater Western Region of Sydney, May 1996. Self-administered survey of clinicians with an involvement or interest in the management of women with breast cancer. Of the 69 respondents to the questionnaire (77% response rate), 20% did not recall ever seeing the guidelines. Although most agreed with the defined parameters of potential strengths of the guidelines, there was less agreement as to their medicolegal implications. The four treatment sections of the guidelines were the most highly rated, followed by the sections on communication skills and investigations. Education programs, including college-based programs, as well as endorsement of the guidelines by the learned colleges and respected colleagues, were rated highly as dissemination strategies, far outranking Internet availability. Local revision of the guidelines was considered important as an implementation strategy by three-quarters of respondents. Only 20% indicated that the guidelines had influenced clinical practice, although 46% agreed that they would improve outcomes for women with early breast cancer. The NHMRC early breast cancer guidelines have been relatively well received in the Greater Western Region of Sydney, although local activities within public institutions and private practice will be needed to achieve implementation.

The Slippery Slope of Health Care Finance: Business Interests and Hospital Reimbursement in Massachusetts

In 1988 Massachusetts enacted a bill, popularly known as Health Care for All, which promised that by 1992 every Massachusetts resident would have available affordable insurance for basic medical expenses. This legislation was one of a series of laws enacted over a period of six years which progressively improved access to care for the uninsured. The policy process which led to the enactment of these laws was strongly influenced by the interests of large employers. This article describes the series of access-expanding hospital reimbursement changes in Massachusetts in the 1980s and traces the connection between the involvement of business interests in the policy process and the outcomes that occurred; that is, it follows the slide of employers down the slippery slope of health care finance. The article also describes a potential implementation strategy for the Health Care for All legislation.

Recruitment order of motor units on voluntary contraction: changes induced by proprioceptive afferent activity.

<h3>Background and aim</h3> The impact of any injury prevention programme is a function of the programme and its implementation. However, real world implementation of injury prevention programmes is challenging. Lower limb injuries (LLIs) are common in community Australian football (community-AF) and it is likely that many could be prevented by implementing exercise-based warm-up programmes for players. This paper describes a systematic, evidence-informed approach used to develop the implementation plan for a LLI prevention programme in community-AF in Victoria, Australia. <h3>Methods</h3> An ecological approach, using Step 5 of the Intervention Mapping health promotion programme planning protocol, was taken. <h3>Results</h3> An implementation advisory group was established to ensure the implementation plan and associated strategies were relevant to the local context. Coaches were identified as the primary programme adopters and implementers within an ecological system including players, other coaches, first-aid providers, and club and league administrators. Social Cognitive Theory was used to identify likely determinants of programme reach, adoption and implementation among coaches (eg, knowledge, beliefs, skills and environment). Diffusion of Innovations theory, the Implementation Drivers framework and available research evidence were used to identify potential implementation strategies including the use of multiple communication channels, programme resources, coach education and mentoring. <h3>Conclusions</h3> A strategic evidence-informed approach to implementing interventions will help maximise their population impact. The approach to implementation planning described in this study relied on an effective researcher-practitioner partnership and active engagement of stakeholders. The identified implementation strategies were informed by theory, evidence and an in-depth understanding of the implementation context.