Robust Implementation Strategy Research Articles

Prevalence of Oral Potentially Malignant Lesions, Tobacco use, and Effect of Cessation Strategies among Solid Waste Management workers in Northern India: a pre-post intervention study

BackgroundIndia bears the highest global burden of oral cancer, despite having an operational tobacco cessation framework. Occupational groups like solid waste management personnel face significant health challenges due to prevalent tobacco use, leading to oral potentially malignant lesions and oral cancer. Enhanced tobacco control strategies are essential for these groups.MethodsA pre-post interventional, community-based study enrolled 1200 municipal workers in Varanasi, India, from July 2022 to August 2023. 858 tobacco users underwent screening and were randomly assigned to one of three interventions: Very Brief Advice, Individual Behavioral Counseling, or Group Behavioral Therapy. Follow-up was conducted one year after the baseline interventions Effectiveness was measured by nicotine dependence reduction using the Fagerstrom Test for Nicotine Dependence (FTND) scores and cessation rates defined as at least 6-month abstinence. Appropriate statistical tests assessed the burden of tobacco use, oral potentially malignant lesions, and pre-post differences in FTND scores within and between groups. A p-value of < 0.05 was considered statistically significant.ResultsMunicipal workers exhibited a high prevalence (71.5%) of smokeless tobacco (SLT) use. One-third (32.9%) of the participants screened positive for oral potentially malignant lesions and oral cancer. Leukoplakia was the most common lesion. Screened positivity correlated with significant nicotine dependence. Among 494 follow-up participants, 47.1% reported a significant reduction in nicotine dependence across all intervention groups. Quade’s ANCOVA indicated significant differences in post-test FTND scores, with individual behavioral counselling showing the greatest reduction. However, no cessation was achieved in any group despite the significant decline in dependence.ConclusionSolid waste management personnel in Varanasi show heightened SLT use and associated oral potentially malignant lesions. The persistent tobacco use in these high-risk occupational populations undermines government tobacco control efforts and highlights the need for robust policy and implementation strategies. The study demonstrated a significant reduction in nicotine dependence following interventions, though tobacco cessation was not achieved. More frequent interventions and addressing quitting barriers—such as cultural norms, lack of awareness, easy accessibility, and adverse working conditions—are crucial. Developing a tailored workplace model to tackle tobacco use in occupational settings may facilitate cessation.Clinical trial registration numberTrial registration Clinical Trials Registry India CTRI/2020/07/026479. Date of registration 10/07/2020.

Developing Effective Counseling Strategies for Visually Impaired Students: Personal, Social, Career, and Academic Perspectives

This study examines the guidance and counseling needs of visually impaired students, emphasizing the importance of tailored programs to address their unique challenges. Using a qualitative approach complemented by quantitative data collection, the research surveyed visually impaired students at SLB – A Karya Murni Medan. The findings reveal that personal needs, such as independent daily living activities, are the highest priority, followed by career needs, including career guidance and decision-making skills. Social needs, involving communication and social interaction, and academic needs, covering fundamental educational skills, were also significant. The analysis underscores the necessity of a comprehensive counseling program designed to support visually impaired students in achieving personal independence, career readiness, social skills development, and academic success. This program should incorporate a thorough understanding of students' needs, clear objectives, and robust implementation strategies to ensure their overall well-being and development.

Acupuncture: Effective and Recommended but More Implementation Needed

Abstract Acupuncture enjoys a robust evidence base for dozens of clinical conditions and decades of research exploring its mechanisms of action. It has over 9,000 positive recommendations from official government and clinical guidelines. However, it still remains relatively inaccessible in the United States, Europe and elsewhere, especially compared to the strength of evidence-based recommendations for its use. Acupuncture would benefit from robust implementation strategies, utilizing insights and approaches from implementation science. The clinical use of Botox for migraine suffered from weaker evidence of effectiveness and greater evidence of harm, but using a streamlined and robust implementation strategy, Allergan was able to achieve widespread implementation from when it began its efforts around 2010. Such a systematic approach that identifies and overcomes barriers to implementation for acupuncture would benefit millions of people who currently are offered less effective and more invasive treatments, contrary to the recommendations of clinical guidelines.

Integrating Artificial Intelligence and Big Data into Smart Healthcare Systems: A Comprehensive Review of Current Practices and Future Directions

The COVID-19 pandemic has unveiled both the vulnerabilities and resilience of global healthcare systems, sparking a surge in innovation, including the accelerated adoption of Artificial Intelligence (AI) and big data analytics. This paper provides a comprehensive examination of the incorporation of these technologies within the advancement of contemporary, intelligent healthcare systems, with a keen focus on their potential to transform health management globally. This study explores the roles of AI and big data in bolstering the adaptability, efficiency, and productivity of healthcare services while also empowering individuals with actionable insights for enhanced health outcomes. Besides identifying key opportunities for AI and big data synergies within smart medical systems - encompassing disease detection and prevention, personalized medicine, resource allocation, and healthcare accessibility - this study delve into the critical ethical considerations accompanying their use. These include the essential principles of explainability, trustworthiness, privacy, security, and healthcare equity. Emphasis is placed on the importance of transparent, accountable, and ethically robust implementation strategies to ensure the responsible deployment of these technologies. Furthermore, the inherent privacy and security challenges associated with big data and AI in healthcare are addressed, detailing potential risks such as data breaches, data misuse, and patient confidentiality threats. Also, this study highlights the significance of incorporating privacy-preserving techniques, such as differential privacy and federated learning, in AI and big data analytics. This paper proposes a forward-looking paradigm for embedding AI and big data analytics within the core infrastructure of smart healthcare systems, outlining best practices and providing recommendations to leverage their transformative potential effectively and ethically. The insights and findings offered aim to guide future research, policy, and implementation efforts focused on harnessing the power of AI and big data to enhance global health resilience, stimulate innovation, and drive constructive change within the realm of intelligent medical facilities.

LM Initiative Success at the Institutional Level Through the RE-AIM Approach: 12 Tips and Implementation Science Strategies

Transforming research into practice via implementation science may improve institution-wide implementation success rates for lifestyle medicine (LM). Implementation science (IS) is the study of methods that facilitate the uptake of evidence-based practice and research into regular use by practitioners and policymakers. Multiple IS frameworks, such as the Reach, Effectiveness, Adoption, Implementation, Maintenance/Practical Robust Implementation Strategy Model (RE-AIM/PRISM) model, Exploration, Preparation, Implementation, Sustainment (EPIS) model, and Consolidated Framework for Implementation Research (CFIR) model, have been developed. IS frameworks provide a strong yet adaptable foundation for launching initiatives, minimizing barriers by challenging implementers to identify and address problems that impede implementation, and promoting long-term sustainability and positive outcomes. The trouble-shooting tips provided in this article are strategically aligned with the RE-AIM/PRISM model of IS to maximize the likelihood of implementation success within the LM space. These tips provide guidance on how to effectively implement interventions, sustain their delivery, and avoid or overcome barriers to implementation. This article presents 12 tips intended as a list of options to facilitate the implementation phases of an initiative, as opposed to offering an all-or-nothing approach to implementation strategy. Current IS priorities emphasize system change and sustainability, which are essential components of successful implementation of LM initiatives.

Implementation outcomes and strategies for delivering evidence-based hypertension interventions in lower-middle-income countries: Evidence from a multi-country consortium for hypertension control.

Guidance on contextually tailored implementation strategies for the prevention, treatment, and control of hypertension is limited in lower-middle income countries (Lower-MIC). To address this limitation, we compiled implementation strategies and accompanying outcomes of evidence-based hypertension interventions currently being implemented in five Lower-MIC. The Global Research on Implementation and Translation Science (GRIT) Coordinating Center (CC) (GRIT-CC) engaged its global network sites at Ghana, Guatemala, India, Kenya, and Vietnam. Purposively sampled implementation science experts completed an electronic survey assessing implementation outcomes, in addition to implementation strategies used in their ongoing hypertension interventions from among 73 strategies within the Expert Recommendations for Implementing Change (ERIC). Experts rated the strategies based on highest priority to their interventions. We analyzed the data by sorting implementation strategies utilized by sites into one of the nine domains in ERIC and summarized the data using frequencies, proportions, and means. Seventeen implementation experts (52.9% men) participated in the exercise. Of Proctor's implementation outcomes identified across sites, all outcomes except for appropriateness were broadly assessed by three or more countries. Overall, 59 out of 73 (81%) strategies were being utilized in the five countries. The highest priority implementation strategies utilized across all five countries focused on evaluative and iterative strategies (e.g., identification of context specific barriers and facilitators) to delivery of patient- and community-level interventions, while the lowest priority was use of financial and infrastructure change strategies. More capacity building strategies (developing stakeholder interrelationships, training and educating stakeholders, and supporting clinicians) were incorporated into interventions implemented in India and Vietnam than Ghana, Kenya, and Guatemala. Although robust implementation strategies are being used in Lower -MICs, there is minimum use of financial and infrastructure change strategies. Our study contributes to the growing literature that demonstrates the use of Expert Recommendations for Implementing Change (ERIC) implementation strategies to deliver evidence-based hypertension interventions in Lower-MICs and will inform future cross-country data harmonization activities in resource-constrained settings.

European Standards of Care for Newborn Health—A project protocol

Among children who receive hospital care, preterm infants are Europe's largest group, whose numbers are continually increasing. Currently, no pan-European standards of care for preterm or critically ill infants are available, except for a few specific topics, and practices vary widely in different regions. The European Foundation for the Care of Newborn Infants (EFCNI) has initiated a transdisciplinary collaboration project to provide agreed standards for high-quality perinatal and neonatal care, whose implementation will ensure fairer and more equitable care across Europe. This will improve care for these vulnerable infants and their families, ameliorate the long-term conditions found in preterm and critically ill infants and enhance the quality of family life of affected families. More than 220 experts-healthcare professionals, patient representatives and other relevant stakeholders-have come together for the first time to develop a broad reference guidance in neonatology and associated fields. Ninety-six standards on 11 overarching topic areas were developed and endorsed. This reference framework serves as a basis for the development of binding national standards for high-quality care. A robust translation and implementation strategy is facilitated, with the goal of improved health outcomes following preterm birth all around Europe.

A New Approach for Developing "Implementation Plans" for Cognitive Stimulation Therapy (CST) in Low and Middle-Income Countries: Results From the CST-International Study.

Background: Even with a strong evidence base, many healthcare interventions fail to be translated to clinical practice due to the absence of robust implementation strategies. For disorders such as Alzheimer's disease and other dementias, access to evidence-based interventions beyond research settings is of great importance. Cognitive Stimulation Therapy (CST) is a brief, group-based intervention, with consistent evidence of effectiveness.Methods: An implementation focused, three-phase methodology was developed using extensive stakeholder engagement. The methods resulted in a standardized Implementation Plan for the successful translation of CST from research to practice. The methodology was developed using the Consolidated Framework for Implementation Research (CFIR) and refined in three countries that vary in levels of economic development and healthcare systems (Brazil, India and Tanzania).Results: Five Implemention Plans for CST were produced. Each plan contained implementation strategies and action plans devised in conjunction with policy professionals, healthcare professionals, people with dementia and family carers, and an international team of researchers and clinicians.Conclusion: This novel methodology can act as a template for implementation studies in diverse healthcare systems across the world. It is an effective means of devising socio-culturally informed Implementation Plans that account for economic realities, health equity and healthcare access.

Human-Centered Design Strategies for Device Selection in mHealth Programs: Development of a Novel Framework and Case Study.

BackgroundDespite the increasing use of remote measurement technologies (RMT) such as wearables or biosensors in health care programs, challenges associated with selecting and implementing these technologies persist. Many health care programs that use RMT rely on commercially available, “off-the-shelf” devices to collect patient data. However, validation of these devices is sparse, the technology landscape is constantly changing, relative benefits between device options are often unclear, and research on patient and health care provider preferences is often lacking.ObjectiveTo address these common challenges, we propose a novel device selection framework extrapolated from human-centered design principles, which are commonly used in de novo digital health product design. We then present a case study in which we used the framework to identify, test, select, and implement off-the-shelf devices for the Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) consortium, a research program using RMT to study central nervous system disease progression.MethodsThe RADAR-CNS device selection framework describes a human-centered approach to device selection for mobile health programs. The framework guides study designers through stakeholder engagement, technology landscaping, rapid proof of concept testing, and creative problem solving to develop device selection criteria and a robust implementation strategy. It also describes a method for considering compromises when tensions between stakeholder needs occur.ResultsThe framework successfully guided device selection for the RADAR-CNS study on relapse in multiple sclerosis. In the initial stage, we engaged a multidisciplinary team of patients, health care professionals, researchers, and technologists to identify our primary device-related goals. We desired regular home-based measurements of gait, balance, fatigue, heart rate, and sleep over the course of the study. However, devices and measurement methods had to be user friendly, secure, and able to produce high quality data. In the second stage, we iteratively refined our strategy and selected devices based on technological and regulatory constraints, user feedback, and research goals. At several points, we used this method to devise compromises that addressed conflicting stakeholder needs. We then implemented a feedback mechanism into the study to gather lessons about devices to improve future versions of the RADAR-CNS program.ConclusionsThe RADAR device selection framework provides a structured yet flexible approach to device selection for health care programs and can be used to systematically approach complex decisions that require teams to consider patient experiences alongside scientific priorities and logistical, technical, or regulatory constraints.

Putting positive weight-related conversations into practice: The pilot implementation of a Knowledge Translation Casebook.

Healthcare professionals (HCPs) play an important role in discussing weight with children and their parents but report barriers such as lack of training and supports. These barriers are especially prevalent within specialized populations such as children with autism spectrum disorder (ASD). To address this, a Knowledge Translation Casebook on positive weight-related conversations was developed by a research team at a Canadian paediatric hospital. The purpose of the current pre-implementation pilot study was to explore initial acceptability and adoption of the Casebook into clinical settings. An interactive, multimodal education workshop was created to provide HCPs with knowledge and training on how to have positive weight-related conversations with children and parents. Two workshops were conducted using the same curriculum but delivered either in-person or online. Participants were drawn from a team of clinicians at a teaching hospital whose care focuses on medication management for clients with ASD and clinicians participating in a distance learning programme on best practice care for clients with ASD. Participants completed a demographic questionnaire, workshop evaluation, and a pre-workshop and post-workshop questionnaire. Descriptive statistics were used to summarize demographic, questionnaire, and survey data. Answers to open-ended questions were analysed using content analysis. Participants agreed that the workshop gave them a clear understanding of the Casebook's content and helped them easily navigate the Casebook. Based on raw scores, self-efficacy in having weight-related conversations seemed to increase from pre-to post-workshop, but reported weight-management clinical practice scores did not change over time. However, the small sample precluded in-depth statistical analysis. The Casebook was acceptable and appeared to increase self-efficacy about having weight-related conversations with children with ASD and parents. More robust implementation strategies are needed to foster the uptake of best practices in weight-related conversations into clinical practice.

Driving organization and systems change toward trauma-responsive services in child welfare: supervisor and administrator perspectives on initial implementation

ABSTRACT Despite trauma as a prevalent and substantial need among children in foster care, child welfare systems are challenged with fully implementing trauma-responsive programs and policies. Furthermore, evidence on effective implementation strategies for trauma-responsive programs in child welfare is scarce. This study’s overarching purpose was to examine child welfare supervisor and administrator views on the initial implementation of a trauma-responsive approach through an organization driver lens. We sought to build knowledge on the ways in which organization drivers of systems intervention, facilitative administration, and decision-support data systems facilitate or inhibit initial implementation. Semi-structured interviews were conducted with 26 child welfare supervisors and administrators implementing a trauma-responsive assessment and case planning approach. Transcripts were coded and analyzed using theoretical thematic analysis. Applying organization drivers to the results, multiple facilitators and barriers were identified. Collectively, findings suggest that implementation of trauma-responsive programs in child welfare should consider all organization drivers as relevant to initial implementation, emphasizing systems intervention and facilitative administration drivers as the most vital to successful implementations. Translational researchers and implementation scientists should strive to identify robust implementation strategies for addressing organization and systems level factors as key supports for initial implementation of trauma-responsive programs and policies.

Structural Design and Data Requirements for Simulation Modelling in HIV/AIDS: A Narrative Review.

Born out of a necessity for fiscal sustainability, simulation modeling is playing an increasingly prominent role in setting priorities for combination implementation strategies for HIV treatment and prevention globally. The design of a model and the data inputted into it are central factors in ensuring credible inferences. We executed a narrative review of a set of dynamic HIV transmission models to comprehensively synthesize and compare the structural design and the quality of evidence used to support each model. We included 19 models representing both generalized and concentrated epidemics, classified as compartmental, agent-based, individual-based microsimulation or hybrid in our review. We focused on four structural components (population construction; model entry, exit and HIV care engagement; HIV disease progression; and the force of HIV infection), and two analytical components (model calibration/validation; and health economic evaluation, including uncertainty analysis). While the models we reviewed focused on a variety of individual interventions and their combinations, their structural designs were relatively homogenous across three of the four focal components, with key structural elements influenced by model type and epidemiological context. In contrast, model entry, exit and HIV care engagement tended to differ most across models, with some health system interactions-particularly HIV testing-not modeled explicitly in many contexts. The quality of data used in the models and the transparency with which the data was presented differed substantially across model components. Representative and high-quality data on health service delivery were most commonly not accessed or were unavailable. The structure of an HIV model should ideally fit its epidemiological context and be able to capture all efficacious treatment and prevention services relevant to a robust combination implementation strategy. Developing standardized guidelines on evidence syntheses for health economic evaluation would improve transparency and help prioritize data collection to reduce decision uncertainty.

Leveraging Health Information Technology in the Quest to Improve Health Care Value.

In the United States, patients receive only half of recommended medical care and nearly a third of the care received may be unnecessary. This disparity between usual and evidence-based clinical practice is associated with a third of hospital deaths and loss of an estimated $380 billion each year.1 The health care industry has invested billions of dollars in electronic medical record systems, believing that it would revolutionize the process of translating evidenced-based guidelines into clinical practice—leading to higher quality care at lower costs, and thereby, improving health care value. Despite these expectations, variability in clinical practice continues for common pediatric diagnoses. Such variability often leads to unsafe, less efficient, and costly health care. However, astute clinicians, policy makers, and payers recognize that evidence-based clinical practice guidelines can make care more reliable and efficient and narrow the evidence practice gap between what clinicians do and what scientific evidence supports. Current strategies to optimize health information technology as a tool to translate evidence into clinical practice include clinical decision support (CDS) tools, such as condition-specific order sets, documentation templates, and best practice advisories.2 Despite these strategies, inconsistences remain in medical care, widening gaps in population-level health experiences and outcomes for common pediatric diagnoses, including asthma, community-acquired pneumonia, and bronchiolitis.3,4 Poor adoption by providers is an important barrier to optimizing health information technology, specifically CDS, as a tool to translate evidence-based recommendations into clinical practice.4 Provider factors, such as their attitudes toward CDS, are typically not addressed during any stage of a CDS development, even though they represent an important factor for adoption.5 It is important to develop strategies that foster partnerships between end users, most often clinicians, and medical informatics personnel to learn what provider factors will enhance CDS adoption. Even a user-centered design CDS tool will not likely completely address the variability in current clinical practice. Thus, we must also focus on robust implementation strategies, which will foster consistent adoption of these tools and sustainability of improvement efforts. We have previously described one conceptual framework associated with sustained improvements in a variety of accountability measures at The Johns Hopkins Hospital.6 The model has also been implemented in 4 other hospitals in the Johns Hopkins Health System to translate evidence into practice and achieved similar improvements in performance measures.7 This model may provide a promising approach to promote CDS adoption and reduce variability in a sustainable manner.6 The model entails (1) clarifying and communicating the goals and measures of interest across all levels of the organization; (2) building capacity and using Lean Sigma or a similar change model for improvement; (3) transparent reporting and ensuring accountability for performance; and (4) developing a sustainability process. Here is how the model could support implementation, using pediatric asthma as an example. First, a multidisciplinary team involving a pediatric pulmonologist and hospitalist, respiratory therapist, nursing, and a pharmacist would agree on the overall goals of the CDS form. They would select or, if needed, identify complementary performance measures inclusive of process and outcome metrics. The aim would be to use national or standardized performance measures when these exist. For example, The Joint Commission has identified 3 performance measures for Children's Asthma Care that pediatric hospitalists should aim to achieve for patients hospitalized to treat asthma. Once the multidisciplinary team identifies appropriate measures, they would partner with health care informatics to integrate these measures into the CDS tool and to build a mechanism to easily track and report performance. The next step would be to implement and test the CDS tool. Implementation would be an iterative process and could use the Lean Sigma “define-measure-analyze-improve-control (DMAIC)”8 or a similar change framework to systematically identify where failures occur and determine ways to improve. It is important to have transparent reporting of performance during this process to ensure accountability and to determine when goals have been consistently achieved over time (step 3). Once goals have been consistently achieved, the last step would be to develop a sustainability plan to ensure that improvements persist outside of the targeted implementation phase. The potential of CDS tools in improving the translation of evidence-based recommendations into clinical practice has not been fully realized. A primary factor has been poor provider adoption of these tools and lackluster implementation strategies. Development of CDS tools should incorporate end user feedback to facilitate improvements in adoption. A comprehensive implementation model that involves end user clinicians in the initiative could promote adoption of such a tool and sustainable improvement of performance measures. The authors plan to study this model as a mechanism to standardize pediatric care.

Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence.

To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature. Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened. The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed. A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions ('User-related changes required to implement PTTSs effectively' and 'Factors that affect user-related changes'), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs. Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system. PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized.

Enhanced recovery protocols after oesophagectomy.

The feasibility and safety of enhanced recovery protocols (ERP) have been demonstrated in a large number of surgical specialties. Several studies have shown improved post-operative outcomes and economic benefit from the use of ERPs in oesophageal cancer surgery. However, these improvements are not always translated more widely into clinical practice due to variation in protocols, poor compliance and failure to implement a robust implementation strategy. ERP implementation strategies should reflect the fact that these are complex interventions that are influenced by a wide range of social, organizational and cultural factors.

An Approach to Quantify the Factors That Affect Performance Measurement System Implementation

Although there have been many important academic advancements in the area of performance measurement systems, many practitioners and researchers still report encountering significant challenges during practical applications. This has led to the development of research to identify factors that affect the success of performance measurement systems. Previous studies attempt to identify and evaluate these factors, but there is little evidence of the inter-relationships and overall effects of various factors on the successful implementation of performance measurement systems. This article describes an exploratory study that applies an existing approach, originally proposed to design performance measurement systems, to investigate the effectiveness of the approach in quantifying the systemic effects of success factors on the implementation of a performance measurement system. The results of this study suggest that applying this approach provides quantitative assessments of the systemic effects of the success factors, which can be used to design more robust implementation strategies.

Delhi's land cover change in post transit era

Growing urbanization and recent Mass Rapid Transit System (MRTS) play an important role in land cover change in Indian cities. However, understanding about direction and magnitude of this change is limited, especially in reference to MRTS introduction, which is required to assess sustainable urban futures. Thus, this study attempts to assess pattern of land cover change, paying special attention to the development of MRTS (both metro lines and stations) in the National Capital Territory of Delhi. Land covers are classified using Landsat images from year 2001 and 2011. In order to measure transformations in developed areas, this study employs maximum likelihood supervised classification and performs buffer analyses along the metro lines and stations. The results reveal that growth of built-up area is higher in peripheral districts, whereas relatively low along the MRTS. This study indicates that ongoing development process needs corrective measures, such as increasing built-up areas across the metro stations and lines, and planned provisioning of physical and social infrastructure in peripheral areas to induce sustainable urban development. To implement these spatial interventions, robust implementation strategies are needed.

Optimal operation of battery-less solar powered reverse osmosis plant for desalination

Small RO based desalination plants driven by solar power are attractive options, especially in areas with unreliable grid power supply. Batteries or other energy storage devices can be used to buffer against the inherent variability in solar power. However, the capital and maintenance cost of batteries and problems associated with their safe disposal renders this option unattractive. The focus of this work is optimal operation of an RO plant driven by solar power without batteries under continuously varying solar radiation intensity. A model of an RO plant driven by solar power without batteries is developed and demonstrated to have adequate predictive capability. The model is used to determine optimal operation policies under two different methods of operation, namely, (i) without storage of permeate and (ii) with permeate storage. Examination of the optimal solution in the first mode of operation reveals that a simple, robust, and model free implementation strategy using active constraint control is possible. Comparison of results show that accounting for the permeate storage results in a higher permeate production, and the buffer tank can be viewed as a surrogate energy storage device.

Effectiveness of interventions to improve patient handover in surgery: A systematic review

Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools. A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria. Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission. Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.

Empowering change: Realist evaluation of a Scottish Government programme to support normal birth

Backgroundmidwife-led care has consistently been found to be safe and effective in reducing routine childbirth interventions and improving women's experience of care. Despite consistent UK policy support for maximising the role of the midwife as the lead care provider for women with healthy pregnancies, implementation has been inconsistent and the persistent use of routine interventions in labour has given rise to concern. In response the Scottish Government initiated Keeping Childbirth Natural and Dynamic (KCND), a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm. Aimthe evaluation was informed by realist evaluation. It aimed to explore and explain the ways in which the KCND programme worked or did not work in different maternity care contexts. Methodsthe evaluation was conducted in three phases. In phase one semi-structured interviews and focus groups were conducted with key informants to elicit the programme theory. At phase two, this theory was tested using a multiple case study approach. Semi-structured interviews and focus groups were conducted and a case record audit was undertaken. In the final phase the programme theory was refined through analyses and interpretation of the data. Setting and participantsthe setting for the evaluation was NHS Scotland. In phase one, 12 national programme stakeholders and 13 consultant midwives participated. In phase two case studies were undertaken in three health boards; overall 73 participants took part in interviews or focus groups. A case record audit was undertaken of all births in Scotland during one week in two consecutive years before and after pathway implementation. Findingsgovernment and health board level commitment to, and support of, the programme signalled its importance and facilitated change. Consultant midwives tailored change strategies, using different approaches in response to the culture of care and inter-professional relationships within contexts. In contexts where practice was already changing KCND was seen as validating and facilitating. In areas where a more medical culture existed there was strong resistance to change from midwives and medical staff and robust implementation strategies were required. Overall the pathways appeared to enable midwives to achieve change. Key conclusionsour study highlighted the importance of those involved in a change programme working across levels of hierarchy within an organisation and from the macro-context of national policy and institutions to the meso-context of regional health service delivery and the micro-context of practitioner's experiences of providing care. The assumptions and propositions that inform programmes of change, which are often left at a tacit level and unexamined by those charged with implementing them, were made explicit. This examination illuminated the roles of the three key change mechanisms adopted in the KCND programme – appointment of consultant midwives as programme champions, multidisciplinary care pathways, and midwife-led care. It revealed the role of the commitment mechanism, which built on the appointment of the local change champions. The analysis indicated that the process of change, despite these clear mechanisms, needed to be adapted to local contexts and responses to the implementation of KCND. Implications for practiceinitial formative evaluation should be conducted prior to development of complex healthcare programmes to ensure that (1) the interventions will address the changes required, (2) key stakeholders who may support or resist change are identified, and (3) appropriate facilitation strategies are developed tailored to context.