Practice Champions Research Articles

Implementing Best Practice Guidelines under the Best Practice Spotlight Organisation: Facilitators and Barriers for Nurses: A Delphi Study.

The implementation and sustainability of evidence-based practice (EBP) is a complex process. Best practice guidelines (BPGs) can facilitate the translation of knowledge from theory into practice, but they require working groups to adapt recommendations and encourage adherence to them. The aim of this study was to identify facilitators and barriers of BPGs in the Registered Nurses' Association of Ontario®, within the framework of Best Practice Spotlight Organisations® (BPSOs®), in a hospital setting. Methods: This study was conducted using the modified Delphi method (two rounds) with a cohort of BPSO® Best Practice Champions. The facilitators and barriers included in the first round were identified through a bibliographic search. The degree of concordance was determined in the second round using the highest mean resulting values. Results: A total of 44 nurses responded, with a mean age of 42.57 ± 8.563. The facilitators included the following: work environment; working in a hospital that encourages research; and dedicating time to EBP (p < 0.001). The barriers included the following: excessive workload; professional mobility (p < 0.001); and lack of time (p = 0.002). Implications for practice: As such, it is necessary to approach human resource management by implementing new policies that guarantee systemic sustainability. The BPSO® programme is an excellent framework for promoting the translation of theoretical knowledge into practice and effecting institutional change.

An automated dispensing cabinet alert influences anesthesia provider medication preparation in a remifentanil waste reduction initiative

Study ObjectiveTo decrease the occurrence of remifentanil waste of 1 mg or more (1 full vial) by 25 % in our surgical division while maintaining satisfaction of 60 % of providers by using a remifentanil mixing workflow. DesignA time series–design quality improvement initiative targeted preventable remifentanil waste. A period of active interventions, followed by a pause and reinstatement of a system intervention, was used to validate its effectiveness. SettingAn academic medical center in the US with 1219 inpatient beds, performing 144,418 surgical cases in 2019 and 127,341 surgical cases in 2020, in 148 operating rooms. InterventionsIndividual- and system-level interventions provided education on the issues of preventable waste, access to a remifentanil dose calculator, and an automated dispensing cabinet (ADC) alert to halt wasteful practice. MeasurementsPreventable remifentanil waste was identified as disposing of intravenous infusion bags containing 1 mg or more or 1 full vial or more of unused medication. Data were retrieved from ADC reports. A preimplementation and postimplementation survey of anesthesia providers assessed workflow attitudes, perceptions, and satisfaction surrounding remifentanil mixing. Main ResultsPreventable remifentanil waste (≥1 mg or ≥ 1 full vial) decreased significantly from 22.0 % of cases using remifentanil at baseline to 16.7 % of cases using remifentanil (odds ratio, 0.71; 95 % CI, 0.60–0.84; P < .001) during the final data collection. Individual-level interventions of education, remifentanil dose calculator, and practice champions did not significantly affect waste while unpaired from the system intervention of the ADC alert. ConclusionsThe implementation of an ADC alert reduced preventable remifentanil waste among anesthesia providers.

Exploring How Patients Are Supported to Use Online Services in Primary Care in England Through "Digital Facilitation": Survey Study.

Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns. As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support. General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services. Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes. General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients.

Bringing a Systems Approach to Living Donor Kidney Transplantation

BackgroundLiving donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure. Efforts to increase LDKT have focused on micro-level interventions and the need for systems thinking has been highlighted. We aimed to identify and compare health system-level attributes and processes that are facilitators and barriers to LDKT. MethodsWe conducted a qualitative comparative case study analysis of three Canadian provincial healthcare systems with variable LDKT performance (Quebec:low, Ontario:moderate-high, British Columbia:high). Data collection entailed semi-structured interviews (n=91), document review (n=97) and focus groups (n=5 with 40 participants), analyzed using inductive thematic analysis. ResultsOur findings showed a strong relationship between the degree of centralized coordination between governing organizations and the capacity to deliver LDKT: 1) Macro-level coordination between governing organizations in British Columbia and Ontario increased capacities, while Québec was seen as decentralized with little formal coordination; 2) A higher degree of centralized coordination facilitated more effective resource deployment in the form of human resources and initiatives in British Columbia and Ontario, whereas in Québec resource deployment relied on hospital budgets leading to competition for resources and reduced capacity of initiatives; 3) Informal resource sharing through strong communities of practice and local champions facilitated LDKT in Ontario and British Columbia and was limited in Québec. ConclusionOur findings suggest that interventions that account for full-system function, particularly macro-level coordination between governing organizations can improve LDKT delivery. Findings may be used to guide structured organizational change towards increasing LDKT and mitigating the global burden of kidney failure.

Multilevel perspectives on the implementation of the collaborative care model for depression and anxiety in primary care

BackgroundThe Collaborative Care Model (CoCM) is an evidence-based mental health treatment in primary care. A greater understanding of the determinants of successful CoCM implementation, particularly the characteristics of multi-level implementers, is needed.MethodsThis study was a process evaluation of the Collaborative Behavioral Health Program (CBHP) study (NCT04321876) in which CoCM was implemented in 11 primary care practices. CBHP implementation included screening for depression and anxiety, referral to CBHP, and treatment with behavioral care managers (BCMs). Interviews were conducted 4- and 15-months post-implementation with BCMs, practice managers, and practice champions (primary care clinicians). We used framework-guided rapid qualitative analysis with the Consolidated Framework for Implementation Research, Version 2.0, focused on the Individuals domain, to analyze response data. These data represented the roles of Mid-Level Leaders (practice managers), Implementation Team Members (clinicians, support staff), Innovation Deliverers (BCMs), and Innovation Recipients (primary care/CBHP patients) and their characteristics (i.e., Need, Capability, Opportunity, Motivation).ResultsMid-level leaders (practice managers) were enthusiastic about CBHP (Motivation), appreciated integrating mental health services into primary care (Need), and had time to assist clinicians (Opportunity). Although CBHP lessened the burden for implementation team members (clinicians, staff; Need), some were hesitant to reallocate patient care (Motivation). Innovation deliverers (BCMs) were eager to deliver CBHP (Motivation) and confident in assisting patients (Capability); their opportunity to deliver CBHP could be limited by clinician referrals (Opportunity). Although CBHP alleviated barriers for innovation recipients (patients; Need), it was difficult to secure services for those with severe conditions (Capability) and certain insurance types (Opportunity).ConclusionsOverall, respondents favored sustaining CoCM and highlighted the positive impacts on the practice, health care team, and patients. Participants emphasized the benefits of integrating mental health services into primary care and how CBHP lessened the burden on clinicians while providing patients with comprehensive care. Barriers to CBHP implementation included ensuring appropriate patient referrals, providing treatment for patients with higher-level needs, and incentivizing clinician engagement. Future CoCM implementation should include strategies focused on education and training, encouraging clinician buy-in, and preparing referral paths for patients with more severe conditions or diverse needs.Trial registrationClinicalTrials.gov(NCT04321876). Registered: March 25,2020. Retrospectively registered.

Middle-Level Managers: Untapped Champions of Evidence-Based Practice?

Purpose: The purpose of this article is to contend that middle-level managers (MMs) are an untapped resource in speech-language pathology to champion the implementation of evidence-based practices in routine clinical settings. Relevant literature is presented related to middle-level managers and their role in closing the research-to-practice gap. We additionally describe empirical examples from related fields and clinical examples from individuals who are conducting this work now in speech-language pathology. Conclusions: Although more research is needed, there is growing evidence that MMs have responsibilities beyond traditional supervisory roles. We argue that they may be key personnel to closing the research-to-practice gap by championing the implementation of evidence-based practice and, as such, we recommend further research and exploration of this innovative area.

Primary care practice-based interventions and their effect on participation in population-based cancer screening programs: a systematic narrative review.

To provide a systematic synthesis of primary care practice-based interventions and their effect on participation in population-based cancer screening programs. Globally, population-based cancer screening programs (bowel, breast, and cervical) have sub-optimal participation rates. Primary healthcare workers (PHCWs) have an important role in facilitating a patient's decision to screen; however, barriers exist to their engagement. It remains unclear how to best optimize the role of PHCWs to increase screening participation. A comprehensive search was conducted from January 2010 until November 2023 in the following databases: Medline (OVID), EMBASE, and CINAHL. Data extraction, quality assessment, and synthesis were conducted. Studies were separated by whether they assessed the effect of a single-component or multi-component intervention and study type. Forty-nine studies were identified, of which 36 originated from the USA. Fifteen studies were investigations of single-component interventions, and 34 studies were of multi-component interventions. Interventions with a positive effect on screening participation were predominantly multi-component, and most included combinations of audit and feedback, provider reminders, practice-facilitated assessment and improvement, and patient education across all screening programs. Regarding bowel screening, provision of screening kits at point-of-care was an effective strategy to increase participation. Taking a 'whole-of-practice approach' and identifying a 'practice champion' were found to be contextual factors of effective interventions.The findings suggest that complex interventions comprised of practitioner-focused and patient-focused components are required to increase cancer screening participation in primary care settings. This study provides novel understanding as to what components and contextual factors should be included in primary care practice-based interventions.

PRAGMATIC IMPLEMENTATION OF AN ADVANCE CARE PLANNING INITIATIVE: MOVING KNOWLEDGE INTO ACTION

Abstract Primary care is an important setting for patient and family-centered communication with older adults given the high frequency of interactions, longitudinal trusted relationships, and patient preferences for advance care planning (ACP). Increasing ACP conversations and documentation of advance directives in primary care is a focus of quality-of-care initiatives and is particularly relevant for older adults, including those with dementia. The SHARING Choices ACP program evaluation was designed to examine the fidelity of implementation with the two partner health systems. SHARING Choices includes a mailing (introductory letter, an agenda-setting checklist, a blank advance directive, and information about shared-portal access for family) sent two weeks prior to scheduled primary care visits for patients aged 65 and above along with access to an ACP facilitator in each practice. Embedding SHARING Choices within primary care practices involved a multi-step process, including onboarding of health system partners, facilitator identification and training, tailored onboarding, practice champion engagement, and practice orientation and ongoing support. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 645 conversations occurred. Most conversations (94.8%) were less than 45 minutes in duration. Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with frontline staff; adapting implementation processes to fit the operational and organizational priorities of the health system.

Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care

Health systems in the US are increasingly screening for social determinants of health (SDOH). However, guidance incorporating stakeholder feedback is limited. To examine patient and care team experiences in early implementation of SDOH screening in primary care. This qualitative study included cross-sectional analysis of SDOH screenings during primary care visits from February 22 to May 10, 2022, primary care team member interviews from July 6, 2022, to March 8, 2023, and patient stakeholder engagement on June 30, 2022. The setting was a large southeastern US health care system. Eligible patients were aged 18 years or older with completed visits in primary care. Screening for SDOH in primary care. Multivariable logistic regression evaluated patient (eg, age, race and ethnicity) and care team characteristics (eg, practice type), and screening completeness. Interviews contextualized the quantitative analysis. There were 78 928 visits in practices conducting any SDOH screening. The population with visits had a mean (SD) age of 57.6 (18.1) years; 48 086 (60.9%) were female, 12 569 (15.9%) Black, 60 578 (76.8%) White, and 3088 (3.9%) Hispanic. A total of 54 611 visits (69.2%) were with a doctor of medicine and 13 035 (16.5%) with a nurse practitioner. Most had no SDOH questions answered (75 298 [95.4%]) followed by all questions (2976 [3.77%]). Logistic regression analysis found that clinician type, patient race, and primary payer were associated with screening likelihood: for clinician type, nurse practitioner (odds ratio [OR], 0.13; 95% CI, 0.03-0.62; P = .01) and physician assistant (OR, 3.11; 95% CI, 1.19-8.10; P = .02); for patient race, Asian (OR, 1.69; 95% CI, 1.25-2.28; P = .001); Black (OR, 1.49; 95% CI, 1.10-2.01; P = .009); or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P = .006); and for primary payer, Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P < .001); managed care (OR, 1.17; 95% CI, 1.07-1.29; P = .001); uninsured or with Access Health (OR, 0.26; 95% CI, 0.10-0.67; P = .005), and Tricare (OR, 0.71; 95% CI, 0.55-0.92; P = .01). Interview themes included barriers (patient hesitancy, time and resources for screening and referrals, and number of questions/content overlap) and facilitators (communication, practice champions, and support for patient needs). This qualitative study presents potential guidance regarding factors that could improve SDOH screening within busy clinical workflows.

Assessment of Adoption and Early Implementation Barriers and Facilitators of the Safe Environment for Every Kid (SEEK) Model.

Although the use of interventions for screening for social determinants of health of families in pediatric primary care clinics has increased in the past decade, research on the barriers and facilitators of implementing such interventions has been limited. We explored barriers, facilitators, and the mechanisms clarifying their roles in the adoption and implementation of the Safe Environment for Every Kid (SEEK) model, an approach for strengthening families, promoting children's health and development, and preventing child maltreatment. A total of 28 semistructured interviews were completed with 9 practice champions, 11 primary care professionals, 5 behavioral health professionals, and 3 nursing/administrative staff representing 12 pediatric primary care practices participating in a larger randomized control trial of implementing SEEK. We identified several barriers and facilitators in the stages of SEEK's adoption and early implementation. Barriers associated with outer and inner setting determinants and poor innovation-organization fit declined in importance over time, while facilitators associated with SEEK characteristics increased in importance based on participants' responses. Barriers and facilitators were linked by mechanisms of comparison and contrast of burdens and benefits, and problem-solving to address limited capacity with available resources. Any screening for and addressing social determinants of health demands greater attention to adoption and implementation mechanisms and the processes by which primary care professionals assess and utilize facilitators to address barriers. This occurs in a context defined by perceived burdens and benefits of innovation adoption and implementation, the capacity of the practice, and changes in perception with experiencing the innovation.

P01 The Australian experience of adapting and implementing ‘To Dip or Not to Dip’ in residential aged care facilities

Abstract Objectives ‘To Dip or Not to Dip’ (TDONTD) is a behavioural intervention focused on reducing inappropriate antibiotic prescribing for urinary tract infections (UTI) by changing urine dipstick testing practice. It was adapted by the Aged Care Quality and Safety Commission from a successful initiative in England’s care homes. We describe TDONTD adaptation and evaluation of TDONTD to support improvement in UTI management in Australian residential aged care facilities. Methods Data were collected in 12 facilities, from November 2021 to July 2022. Baseline and 3 month interviews were conducted with nurse and pharmacist champions implementing TDONTD and antibiotic prescribing audits. Results Australia’s most widely accepted national guideline for assessment of residents with suspected UTI discourages urine testing in asymptomatic persons, however, is not explicit on when to (or not) perform dipstick testing in residents who do not meet minimum criteria for UTI. We adapted key resources including case-based education, clinical pathway for assessing residents for suspected UTI and antibiotic audit tool to incorporate national guideline recommendations around dipstick testing. Surveys with nurse champions of urine dipstick practice showed improved practice in the facilities related to reduced testing for asymptomatic bacteriuria (ASB) and increased use of formal protocol to guide dipstick testing practice and UTI diagnosis. Qualitative interviews with champions identified: (i) increased knowledge around ASB, clinical signs and symptoms of suspected UTI; (ii) increased confidence in not relying on dipstick testing to diagnose suspected UTI; (iii) TDONTD challenged and changed nurse perceptions of how residents present with UTI; (iv) pressure from external healthcare professional providers and family to perform dipstick testing was common; and (v) TDONTD was a feasible intervention in Australian RACF setting. Oral antibiotic prescribing for all indications, including UTI, improved with the intervention as did prescribing appropriateness for UTI treatment but not prophylaxis (Table 1). Table 1.Oral antibiotic prescriptions for UTI at baseline, 3 months and 6 monthsOral antibiotic prescriptionsBaseline (%), 1074 residents3 months (%), 1054 residents6 months (%), 634 residentsFor all indications7.95.25.1For UTI32.61.6By appropriateness (indication and duration) For UTI treatment2758100 For UTI prophylaxis61814 Conclusions We found that TDONTD supported improved clinical management of residents with suspected UTI in an Australian aged care setting. Knowledge, skills and environmental context and resources contributed towards practice change. External healthcare professional providers and family were barriers to change suggesting that education around dipstick testing should be expanded to broader community and hospital healthcare settings in Australia.

A Team-Based Training for Continuous Glucose Monitoring in Diabetes Care: Mixed Methods Pilot Implementation Study in Primary Care Practices.

The American Academy of Family Physicians (AAFP) develops and maintains continuing medical education that is relevant to modern primary care practices. One continuing medical education modality is AAFP TIPS, which are comprised of resources designed for family medicine physicians and their care teams that aid in quick and accessible practice improvement strategies, with actionable steps. Evaluating physicians' use of and satisfaction with this modality's content and implementation strategies has not been prioritized previously. Continuous glucose monitoring (CGM) plays an increasing role in the treatment of diabetes; uptake occurs more rapidly in endocrinology settings than in primary care settings. To help address such differences in CGM uptake and diabetes care, AAFP TIPS on Continuous Glucose Monitoring (AAFP TIPS CGM) was developed, using published evidence and input from content experts (family medicine faculty; AAFP staff; and an advisory group comprised of other primary care physicians, patients, a pharmacist, and a primary care practice facilitator). A pilot implementation project was conducted in 3 primary care practices. To evaluate AAFP TIPS CGM in primary care practices, the research team assessed use of and satisfaction with the content and assessed barriers to and facilitators for strategy and workflow implementation. In total, 3 primary care practices participated in a mixed methods pilot implementation of AAFP TIPS CGM between June and October 2021. Practice champions at each site completed AAFP TIPS CGM and baseline practice surveys to evaluate practice characteristics and CGM prescribing. They conducted team trainings (via webinars or in person), with the goals of implementing CGM into practice and establishing or improving CGM workflows. Practice champions and team training participants completed posttraining surveys to evaluate the training, AAFP TIPS materials, and likelihood of implementing CGM. Interviews were conducted with 6 physicians, including practice champions, 2 months after team training. Satisfaction surveys were also distributed to those who completed the AAFP TIPS CGM course via the internet during the study period. Of the 3 practices, 2 conducted team trainings. The team training evaluation survey showed that practice staff understood their role in implementing CGM in practice (19/20, 95%), and most (11/20, 55%) did not have questions after the training. Insurance coverage for CGM was a remaining knowledge gap and potential barrier to implementing CGM in practice. Physicians and interdisciplinary care team members who took the AAFP TIPS CGM course via the internet, as well as those who attended in-person team training, expressed a high degree of satisfaction with the education, content, and applicability of the course. This pilot implementation of AAFP TIPS CGM offers pertinent and timely information for primary care practices that desire to initiate or expand CGM use to best meet the needs of their patients with diabetes.

Evaluation of an Academic Detailing Program to Improve Blood Pressure Measurement and Hypertension Treatment in Urban Community Health Centers.

Hypertension is estimated at a prevalence of 30 to 50% in the United States. Only 54% of patients with hypertension have their condition adequately controlled. This study aimed to use academic detailing (AD) to improve practice team knowledge and confidence in blood pressure (BP) management, specifically in low-income, underresourced patient populations. AD was developed for five practices that care for high percentages of Medicaid-eligible patients. A needs assessment was administered to each site's practice champion to determine high-yield AD sessions for their team. Presession and postsession evaluations were completed by practice team members. Fifty providers and eight staff member participants completed evaluations over nine sessions for two AD topics at four practice sites. Statistical significance was found for several items within sessions including accurately choosing cuff sizes and identifying barriers to home BP monitoring. AD is a potentially financially efficient model to improve knowledge and confidence in hypertension care at the practice level. Tailoring session content to specific needs of a practice site, along with an identified practice champion, facilitated implementation of the program. This replicable model is one way to deliver evidence-based information to those who serve Medicaid-eligible patients.

852: IMPROVING KNOWLEDGE AND CONFIDENCE WITH BETA-LACTAM THERAPEUTIC DRUG MONITORING IN THE ICU

Introduction: Beta-lactam antibiotics are the backbone of sepsis treatment, but a ‘one-size-fits-all’ dosing strategy leads to unpredictable effects. Therapeutic drug monitoring (TDM; i.e., drug level testing) can personalize treatment and improve outcomes. Pharmacists are the key operational stakeholders for beta-lactam TDM in the ICU, but evidence suggests they have low knowledge and confidence with the practice. We hypothesized that delivery of bundled education intervention would increase pharmacist knowledge and confidence about beta-lactam TDM without jeopardizing the proportion that feel such a program is worthwhile. Methods: A questionnaire was developed and distributed to critical care and infectious diseases pharmacists at a large academic medical center before and after delivery of a bundled educational intervention on beta-lactam TDM. Component parts of the education included a web-based asynchronous learning module on beta-lactam TDM, an electronically available pharmacokinetic calculator, infographics of key content and workflow processes, a frequently asked questions document, and practice champion training. Questionnaire items were based on the ADKAR framework (awareness, desire, knowledge, ability, and reinforcement). Results were summarized descriptively and the Chi-square test was used for two-way binary comparisons. Results: Of 66 available pharmacists, 55 (83%) and 35 (53%) responded to the baseline and follow-up (after the educational intervention) questionnaires. Significantly more respondents felt comfortable recommending beta-lactam TDM for infected critically ill patients after the educational intervention (29% vs 97%; P < 0.001). Familiarity with operational considerations were similarly improved including with patient selection, number and timing of samples, and application of results. The proportion of respondents who felt beta-lactam TDM was worthwhile increased from 60% to 80% after education (P = 0.002). Conclusions: A bundled education intervention can increase knowledge, comfortability, and confidence with beta-lactam TDM in the critically ill among pharmacists, the key operational stakeholders.

Implementing collaborative learning in practice in a London maternity ward

A collaborative learning in practice pilot study in a maternity unit in a London Trust has been carried out. Collaborative learning in practice is a model for supervising students where they work in small groups under the guidance of a practice supervisor. The pilot found that the model is a possible approach to increasing placement capacity that provides an equally enriching, if not improved, learning experience. Improvements were seen in peer support, confidence and responsibility, teamwork skills, new learning opportunities and being better prepared for practice after graduation. Reflecting on the experience of implementing the first cycle of the pilot, this article provides guidance to healthcare education providers for implementing the model in practice placements. The guidance offers a modified model, establishing key personnel as collaborative learning in practice champions and providing adequate preparation for students, staff and the environment.

An exploratory case study investigating the implementation of a novel knowledge translation strategy in a pandemic: the Pandemic Practice Champion

BackgroundThe clinical Pandemic Practice Champion (PPC) role was created in a large tertiary pediatric hospital as a knowledge translation (KT) strategy for implementing COVID-19 evidence-based knowledge. We aimed to describe the core components of the PPC role, the process of implementing the role, and the factors that hindered or facilitated role implementation.MethodsAn exploratory case study was undertaken. Semi-structured interviews were conducted virtually with stakeholders including PPC, managers, and front-line health care professionals (HCP). A directed approach to qualitative content analysis consistent with the Consolidated Framework for Implementation Research (CFIR) guided the analytic process. Inductive analyses and three stages of thematic synthesis were also conducted.ResultsFour PPC, 3 managers, and 6 HCP were interviewed. The core components of the PPC role consisted of (a) acting as knowledge experts and educators, (b) problem-solving for complex patient care issues, (c) conducting crisis management, and (d) acting as a resource to management, HCP, and families. Facilitators for successful implementation included access to external information, a supportive organizational context and culture, dedicated time and resources, and leadership support. Lack of clarity of role definition, insufficient time, pandemic uncertainty and fatigue, inability to change infrastructure, and access to external information hindered implementation.ConclusionThe PPC role was successfully implemented within a crisis context. Key barriers (role clarity, time, resources) and facilitators (organizational and leadership support) need to be considered when implementing the PPC role in practice. Future studies are needed to determine the intervention effectiveness of the champion role in changing HCP behavior and health outcomes and further examine implementation processes and mechanisms.

Australian general practice experiences of implementing a structured approach to initiating advance care planning and palliative care: a qualitative study

ObjectivesInitiation of advance care planning (ACP) and palliative care (PC) assessments in general practice is key to quality end-of-life care. The Advance Project promotes a team-based approach to initiating ACP...

Improvements in appropriate ambulatory antibiotic prescribing using a bundled antibiotic stewardship intervention in general pediatrics practices.

To improve appropriate antibiotic prescribing for children in Tennessee. We performed a before-and-after intervention study with 3 comparison periods: period 1 (P1, baseline) May 2018-September 2019; period 2 (P2, intervention before the COVID-19 pandemic) November 11, 2019-March 20, 2020; and period 3 (P3, intervention during the coronavirus disease 2019 [COVID-19] pandemic) March 21, 2020-November 10, 2020. We additionally surveyed participating providers to assess acceptance of the intervention. Community general pediatrics practices. In total, 81 general pediatricians, family medicine physicians, and nurse practitioners in 5 general pediatrics practices participated in this study. Each practice identified a practice and operations champion for the project. Practices chose 2-4 implementation strategies previously shown to be effective at reducing outpatient antibiotic use to implement in their practice throughout the study intervention period. Study personnel also held quarterly meetings with all providers to review deidentified peer comparison feedback both across practices enrolled in the study and at the provider level within each practice. We detected improvements in guideline-concordant antibiotic use in the pre-COVID-19 intervention period, and they were sustained in the study period during the pandemic (P3): otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%). Bundled implementation strategies led to significant increases in guideline-concordant antibiotic prescribing for all diagnoses. Survey results demonstrate that the bundled implementation strategies were well-accepted by providers.

Implementation of remote asthma consulting in general practice in response to the COVID-19 pandemic: an evaluation using extended Normalisation Process Theory.

BackgroundThe COVID-19 pandemic has led to the rapid and reactive deployment of remote consulting in UK general practice. The delivery of acute and chronic asthma care has been affected. Extended Normalisation Process Theory (eNPT) provides a framework for evaluating the implementation of new complex interventions in routine practice, including examination of how context–intervention interactions affect implementation.AimTo explore the implementation of remote asthma consulting in UK general practice in response to the COVID-19 pandemic.Design & settingMixed-methods evaluation, which was informed by eNPT, in general practice in Northern Ireland.MethodData were collected from a range of healthcare professionals who provide asthma care using online questionnaires, interviews, and multidisciplinary focus groups. Analysis was informed by eNPT.ResultsTen themes were identified to describe and explain the contribution of general practice staff to implementation of remote asthma consulting. Staff identified novel alternatives to in-person review. Having a practice champion to drive implementation forward, and engage other practice staff, was important. Patient, staff, and healthcare system-contextual factors influencing implementation were identified including access to, understanding of, and willingness to use the technology required for remote consulting.ConclusionThe experiences of frontline healthcare professionals in this study indicate that remote asthma consulting has potential benefits in terms of access and effectiveness when implementation integrates seamlessly with face-to-face care for those who want or need it. Work is required at practice and healthcare system levels to realise this potential, and ensure implementation does not exacerbate existing healthcare inequalities.

Exploration of Barriers and Facilitators to Implementing Best Practice in Exercise Medicine in Primary Pediatric Care-Pediatrician Perspectives.

Despite the known health benefits of physical activity (PA), few primary care pediatricians discuss, evaluate, or prescribe PA for children. The goal of this study was to examine pediatricians' thoughts and practices related to child PA and the perceived facilitators and barriers to implementing PA evaluation and prescription in pediatric primary care clinics. The Consolidated Framework for Implementation Research was used to explore implementation barriers and facilitators. A mixed-method design combined questionnaires and focus groups with 27 pediatricians. Despite the pediatricians' beliefs that PA is important for patients, there was wide practice variability in their approaches to discussing PA. Several perceived barriers to implementing PA evaluation and prescription were identified, including lack of knowledge and training, managing time for PA with multiple demands, the need for a team approach and simple PA tools and resources, support for patient tailoring of PA messaging, and a need for PA best practice champions. The identified barriers to implementing evidence in PA suggest several directions for improvement, including a care-team approach; quick, inexpensive, and simple PA tools; community PA partnerships; PA training in medical education; evidence-based strategies; and PA directories for families. These efforts could facilitate the implementation of PA best practices in pediatrics.