Site-specific Implementation Research Articles

Influence of a community practice innovation on a statewide cancer drug repository network.

115 Background: Cancer drug repositories (CDRs) have the potential to minimize cancer medication waste while improving medication access to patients in need. Despite multiple states having legislation allowing for CDR programs, implementation remains suboptimal. The first CDRs to launch in Michigan were a fortuitous result of the support provided in embedding clinical pharmacists into community oncology practices via the Pharmacists Optimizing Oncology Care Excellence in Michigan, POEM, program. We describe these grassroot efforts as well as barriers to sustainability, ultimately resulting in formation of a statewide CDR Network, YesRx. Methods: This qualitative analysis of barriers and facilitators was conducted from interviews with Michigan’s first CDRs. Virtual group meetings were conducted monthly for 6-months from January 2023 – June 2023. Meetings were led by the coordinating center team of POEM. Workgroup attendees included POEM pharmacists who established the first 3 CDR programs in the State, a medical oncologist and longstanding advocate of CDRs, and a patient representative. Brainstorming sessions included open ended questions on experiences to date, benefits of CDR programs, barriers to growth, limitations in current CDR models, and beneficial areas for support. Interview findings were categorized as barriers or facilitators of site-specific implementation and recommendations for CDR model optimization. Results: All 3 CDRs reported positive outcomes from initiating the CDRs related to patient benefit and physician satisfaction. Items reported as challenges/barriers in the sustainability of individual site-managed CDRs: space (inventory growth exceeded designated storage capacity), complexity of inventory tracking, resources (staff and financial), inability to search state-wide for available inventory, inability to easily transfer medications between CDR sites (due to cost, documentation, and staff), inability to ship medications directly to a patient’s home, inability to serve cancer patients across the State who may be in need of medication or interested in donating. The top recommendations for CDR model optimization formed by this workgroup were a centralized, shared database of CDR inventory across the State, support for CDR medication transfers, and additional resource and storage capabilities. YesRx, a nonprofit service organization, was founded in July 2023 in collaboration with the first 3 CDRs to address the experienced barriers resulting in exponential state-wide access. Conclusions: Grassroot efforts of community-based clinical oncology pharmacists resulted in the first CDR programs in Michigan and their experiences guided the launch of a statewide network of CDRs created to expand cancer medication access for vulnerable and underserved people and communities.

Fidelity of Enhanced Recovery Protocol Implementation With Assessment of Hospital-Specific Materials

IntroductionVariability in implementation of enhanced recovery protocols (ERPs) often reduces the effects of an intervention on clinical outcomes. This study aimed to evaluate hospital-level implementation fidelity to a pediatric gastrointestinal surgery ERP by assessing site-specific implementation materials. MethodsThis document analysis study operationalized implementation fidelity as adherence to the creation of specified materials at each study site. During the 12-mo implementation phase within the stepped-wedge cluster randomized control trial, ENhanced Recovery In CHildren Undergoing Surgery, study sites were provided with materials (e.g., order sets), access to peer-counseling, and given key ERP elements spanning multiple phases of care. Sixteen of the 18 total study sites submitted implementation materials, including 14 anesthesia protocols, 11 order sets, and 16 sets of patient/family education materials. These materials were assessed and graded for fidelity using prespecified criteria. Hospital-level fidelity scores could range from 0 to a maximum score of 18, and were categorized as either high or low, based on whether the score was above or below/equal to the median. Descriptive statistics and Wilcoxon rank sum test were used for analysis. ResultsThe overall hospital-level median fidelity score for inclusion of ERP elements in the implementation materials was 10.5. The median score was 12.8 at nine high-fidelity sites and was 5.6 at nine low-fidelity sites (P < 0.01). Higher adherence was noted for avoiding prolonged fasting (n = 16/18 hospitals; 89%) and preventing nausea and vomiting (n = 16/18 hospitals; 89%) in anesthesia protocols and/or order sets. Lower adherence was noted for incorporation of minimally invasive surgical techniques (n = 2/18 hospitals, 11%) and of preoperative optimization of medical comorbidities (n = 0/18 hospitals, 0%) in implementation materials. ConclusionsDespite substantial resources to promote ERP elements, there was wide variation in fidelity for incorporating ERPs into implementation materials among hospital sites. Development of high-fidelity implementation materials for complex ERPs for gastrointestinal surgery in children may require longer than 12 months. Additional implementation strategies, resources, and modification of implementation-focused materials may be needed.

Results from Multisite Implementation of Electronic Health Record Tools for Clinical Pre-Test Probability of Pulmonary Embolism in the Emergency Department

Introduction: Use of validated risk stratification tools for work up of suspected pulmonary embolism (PE) is an endorsed recommendation of the American Society of Hematology and the American College of Emergency Physicians. Due to variations in clinical practice, electronic health record (EHR) systems, and medical provider trainings, the use, documentation, and implementation of these tools vary widely. Current processes do not allow for electronic capture and quality reporting at most institutions. Methods: We sought to design and implement clinical pre-test probability (PTP) tools at three large healthcare institutions for use in emergency departments (ED). At each site, a hematologist partnered with ED physician leadership and local information technology experts to design and implement PTP tools in clinical workflows. Overall, 38 EDs (high volume tertiary EDs and smaller regional EDs) located in the United States along the East Coast and Midwest regions were involved. A major goal of implementation was integration into clinical workflow and automatic documentation. After design and implementation, awareness and education of the new EHR tool was distributed electronically to ED providers. After implementation, use of PTP tools was analyzed between September 12, 2022 and January 11, 2023. PTP use was examined as percent of visits for which patients underwent CT pulmonary angiography (CTPA). Results: Each institution chose the 3 tier Wells' Score for implementation while one site designed an integrated Wells'/PERC or YEARS score calculator. Two sites implemented the tool as an optional flowsheet and one site implemented the tool as mandatory parameters within the orders for PE imaging studies. The mandatory tool could be bypassed with prespecified selections or if a D-dimer existed within 48 hours . Complete details of the site-specific implementation are shown in Table 1. Over the 4-month evaluation timeframe, there was a total of 270,214 ED encounters. Uptake and utilization of the PTP tools are shown in Table 2. Use of PTP was highest at the site with forced PTP documentation which ranged from 49-53% of ordered CTPAs, compared to Site 2 where use was 2-3%, and Site 1 where use ranged from 1-3%. At Site 1, use of PTP increased slightly over the study period with signs that PE yield on imaging was increasing as well (3.4% to 5.9%). At Site 2, PE yield on imaging was overall high (9-10%), and remained similar with similar use of PTP tools over the study period. Use of PTP and PE yield (6-8%) on imaging also remained similar throughout the study at Site 3. Conclusion: Forced use of PTP within the orders for CTPA led to the highest use of PTP (Site 3) but this did not result in meaningfully higher PE yield on CTPA compared to the other sites. PE yield at each site was at or above the 5% yield for PE on CTPA which has been previously reported. Given that PTP uptake was relatively stable over the measurement period at Site 2 and 3, this indicates the process had mostly stabilized and that other strategies are needed to improve uptake of PTP, reduce utilization of CTPA, and further increase yield on CTPA. Increasing PTP use and rising PE yield at Site 1 demonstrated ongoing potential for improvements past this study timeframe.

A progress update on the implementation of a multi-faceted intervention to spread and scale bronchiolitis appropriate care in Alberta

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Successful implementation of an audit and feedback (A&amp;F) intervention at the Alberta Children’s Hospital (ACH) reduced use of low-value interventions and tests for bronchiolitis. Opportunities to improve bronchiolitis management are likely also present in other urban and rural settings. This project will spread and scale the work completed at ACH to 16 sites across Alberta focusing on children under one-year diagnosed with bronchiolitis who managed both in ED and inpatient settings.&#x0D; &#x0D; Methods: Site implementation included two key aspects:&#x0D; &#x0D; Audit &amp; Feedback (A&amp;F) – review practice data, facilitated discussion with clinicians and their teams, and identify enablers and barriers to practice change.&#x0D; &#x0D; The seasonality of bronchiolitis cases (November to April) helped inform the frequency of A&amp;F feedback reports: mid-season (February) and end-of-season (April)&#x0D; Clinical dashboards are being developed within the new clinical information system – ConnectCare - that will provide teams with real-time feedback on potential practice change.&#x0D; &#x0D; &#x0D; Site Specific Implementation Plan – Resources are tailored to fit site needs including the use of posters, handouts and practice guidelines; utilization of order sets; and staff and family education resources.&#x0D; &#x0D; The bronchiolitis initiative is eligible for Continuing Medical Education accreditation through a newly developed easy-to-navigate web-based tool, My Practice Improvement – MyPI. An Education Working Group consisting of patient and family advisors was developed. Family resources included a QR code handout to a “How to suction your baby’s nose” instructional video to help parents/families care for their child at home. The HEAL handout provided links to additional resources for families. Family centred care participants were consulted on the development of a family resource: “Bronchiolitis: A roadmap from admission until discharge”.&#x0D; &#x0D; Evaluation Methods: The primary objective of the study is a 25% absolute reduction in chest radiograph use. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Return visits to the ED within 72 hours of discharge will be monitored as a balancing measure to assess potential unintended consequences of de-implementing low-value tests and interventions in the ED. The provincial rollout of ConnectCare and tableau dashboard integration will enable a broader array of tests and treatments that are used in the management of bronchiolitis to be reported. The spread and scale of this project has now engaged with ED sites in non-tertiary settings in urban and rural areas where patient demographics and resource availability could pose additional challenges. Providing education and resources for these sites is one way to ensure equitable healthcare access for all Albertans.&#x0D; &#x0D; Results: Six facilities implemented rollout from September to November 2021 with a total of 151 physicians attending the A&amp;F sessions. Chest x-ray use at sites that had a 2021 session compared to sites with a planned session in 2022 revealed a decrease after one bronchiolitis season. A difference in difference analysis between the two groups demonstrated that sites with a 2021 session had a -14.3% (95%CI -21.4 to -7.1) decrease in chest x-ray use. As of November 17, 2022, there have been 12 A&amp;F sessions attended by 255 physicians, nurses and respiratory therapists.&#x0D; &#x0D; Advice and Lessons Learned: &#x0D; &#x0D; Capacity for scale and spread intiatives should be accounted for early in planning processes. We brought on two additional medical leads to facilitate sessions in fall 2022 due to an increase in the number of sites involved. Without the additional assistance, the success of roll out may have been jeopardized.&#x0D; Flexibility is key. Several sites across the province are continuing to deal with staffing shortages and recent high volumes of influenza, RSV and COVID are putting EDs over capacity. Sites have demonstrated incredible flexibility with engagement and session availabiltiy despite these circumstances. We changed session dates to help balance workloads as some sites had ConnectCare implementation concurrent with the start of the bronchiolitis season.&#x0D;

Scale and spread of quality improvement initiatives for bronchiolitis management in Alberta emergency departments

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Practice guidelines do not recommend routine use of certain diagnostic tests and medications in managing bronchiolitis, yet prior studies suggest that low-value interventions are routinely administered to patients with bronchiolitis. Successful implementation of quality improvement at the Alberta Children’s Hospital suggested that low-value interventions and tests can be improved. Yet, practice variation and potential opportunities to improve bronchiolitis management are likely present in EDs in urban and rural settings.&#x0D; Implementation: The project is a collaboration between the Maternal Newborn Child and Youth Strategic Clinical Network (MNCY SCN), the Improving Health Outcomes Together Team (IHOT), and Physician Learning Program (PLP) under the umbrella of the AHS Ernst &amp; Young Clinical Appropriateness Theme recommendations to expand and scale initiatives to reduce unnecessary tests to improve patient safety. A provincial Bronchiolitis Steering Committee, led by two Physician Initiative Leads, was formed to guide the project and implementation at 16 facilities across Alberta.&#x0D; Site implementation includes two key aspects:&#x0D; &#x0D; Audit &amp; Feedback (A&amp;F) – review practice data, facilitated discussion with clinicians, and identify enablers and barriers to practice change&#x0D; Site Specific Implementation Plan – options for sites include use of posters, tools, resources; utilization of ConnectCare (order sets); and staff and physician education&#x0D; &#x0D; Qualitative interviews with site-champions will provide perspectives and feedback on enablers and barriers to change. Discussions from the A&amp;F sessions, in addition to the qualitative interviews will be coded and analyzed based on the Consolidated Framework for Implementation Research and Theoretical Domains Framework.&#x0D; Resources required included clinical leads, project management, data/dashboards, educational posters, updated order sets, and a central location for staff and physician to access bronchiolitis materials (via SharePoint).&#x0D; Evaluation Methods: The primary objective of the study is a reduction of chest x-ray utilization. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Secondary measures include medications (PIN) and respiratory viral testing. There is strong evidence to support that medications and respiratory viral testing do not impact bronchiolitis management. The project addresses patient safety and outcomes by reducing the use of low-value interventions and tests in the ED and enables resources to be directed towards evidence-based care. As ConnectCare is phased into all facilities across Alberta, additional metrics will be incorporated into reports and updates to participating sites.&#x0D; Results: The first phase of the project took place from September to November 2021, with rollout to six facilities (four EDs and two inpatient units). A total of 151 physicians attended the audit and group feedback sessions. Site-specific planning sessions and qualitative interviews with site-champions are planned, and the next phase of the project will continue with spread and scale to regional EDs (n=5), urban (n=2) and rural (n=4) locations in fall 2022. &#x0D; Advice and Lessons Learned: &#x0D; &#x0D; The partnership with MNCY SCN, PLP, IHOT, and two Clinician Leads has been beneficial for establishing a team-based multi-disciplinary approach to address needs as they arise and the ability to work together with site champions.&#x0D; Identifying and collaborating with site champions is necessary for establishing relationships and trust prior to conducting audit and feedback sessions and addressing practice change. Site champions understand the contextual factors of their facility and how to best utilize enablers or address barriers for practice change. Initiation of these working relationships need to take place months before implementation and ideally develop through existing networks.&#x0D; Timing and flexibility are crucial for successful implementation. Rescheduling launch dates, adjusting session time, validating data, and adjusting to external factors such as delays in ConnectCare rollouts and pressures on the healthcare system brought on by the COVID-19 pandemic were experienced in the planning and initiating phases of the project. These lessons will be carried forward as we plan for the second part of spread and scale in Fall 2022.&#x0D;

Using activity-based therapy for individuals with spinal cord injury or disease: Interviews with physical and occupational therapists in rehabilitation hospitals

Objective: To understand if and how physical therapists (PTs) and occupational therapists (OTs) use activity-based therapy (ABT) and its associated technologies for the rehabilitation of individuals living with spinal cord injury or disease (SCI/D) in Canadian rehabilitation hospital settings. Design: Qualitative study. Setting: Through rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry, we recruited licensed OTs and PTs to participate in focus groups. Participants: Twelve PTs and ten OTs from nine sites across eight provinces participated. Outcome Measures: To inform the development of a semi-structured interview guide, we used the Theoretical Domains Framework. To analyze the data, we used interpretive description. Results: We identified three themes that influenced therapists’ use of ABT and associated technologies for SCI/D rehabilitation. (1) Therapists’ decision-making approach to ABT and technology. Therapist roles, site-specific dynamics and goal setting influenced decision-making. Assuming roles such as mentor, liaison and advocate led to more ABT use. Site-specific dynamics concerned levels of ABT knowledge, teamwork, and staffing. In hospital rehabilitation, there was competition between discharge and neurorecovery goals. (2) Therapist perceived individual factors. Patient factors either increased (i.e. patients’ motivation, self-advocacy) or prevented (i.e. mourning period, tolerance) the likelihood that ABT was introduced by therapists. (3) ABT and equipment access. Technology was used for ABT in a variety of ways. Access was affected by visible (e.g. equipment cost) and invisible barriers (e.g. departmental relations). Conclusions: The use of ABT and its associated technologies in Canadian rehabilitation hospitals is variable. Ongoing education could be offered, and site-specific implementation strategies could be developed, to promote ABT use.

An Evaluation of Texture-Modified Diets Compliant with the International Dysphagia Diet Standardization Initiative in Aged-Care Facilities Using the Consolidated Framework for Implementation Research.

Texture-modified diets (TMDs) are commonly prescribed for older adults with swallowing difficulties to improve swallowing safety. The International Dysphagia Diet Standardization Initiative (IDDSI) provides a framework for terminology, definitions and testing of TMDs. This observational mixed-method study used the consolidated framework for implementation research (CFIR) to establish the barriers and enablers to IDDSI adoption in aged-care facilities (ACFs). Five New Zealand ACFs who had adopted IDDSI > 12months previously were recruited. Evaluation tools were developed based on CFIR constructs, integrating data from (i) mealtime observations; (ii) manager interviews and (iii) staff (nursing, carers and kitchen) self-administrated surveys. All facility and kitchen managers were IDDSI aware and had access to online resources. Three sites had changed to commercially compliant products post-IDDSI adoption, which had cost implications. Awareness of IDDSI amongst staff ranged from 5 to 79% and < 50% of staff surveyed felt sufficiently trained. Awareness was greater in large sites and where IDDSI was mandated by head office. Managers had not mandated auditing and they felt this had led to reduced perceived importance. Managers felt staff required more training and staff wanted more training, believing it would improve food safety and quality of care. Lack of a dedicated project leader and no speech pathologist on-site were perceived barriers. Collaboration between healthcare assistants, kitchen staff and allied health assisted implementation. ACF staff were aware of IDDSI but staff awareness was low. Using the CFIR, site specific and generic barriers and enablers were identified to improve future implementation effectiveness. Managers and staff want access to regular training. Multidisciplinary collaboration and improving communication are essential. ACFs should consider TMD auditing regularly. Successful implementation of IDDSI allows improvement of quality of care and patient safety but requires a systematic, site-specific implementation plan.

Assessment of patient navigation programs for breast cancer patients across the city of Boston.

Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited system-based approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city. We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n= 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care. All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient's cancer treatment. The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients' health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention. Clinical Trial Registration Number NCT03514433, 5/2/2018.

Using Technology to Enhance Activity-Based Therapy for Individuals with Spinal Cord Injury or Disease: Rehabilitation Hospital Therapists’ Perspectives

<h3>Research Objectives</h3> To understand if and how therapists use technology and/or activity-based therapy (ABT) for rehabilitation of individuals living with spinal cord injury or disease (SCI/D). <h3>Design</h3> This research design was an exploratory qualitative study involving focus groups. The development of the semi-structured interview guide was informed by the Theoretical Domains Framework. <h3>Setting</h3> The settings consisted of inpatient/outpatient departments at nine Canadian rehabilitation hospitals. <h3>Participants</h3> Participants included licensed physical (n=12) and occupational (n=10) therapists employed at rehabilitation hospitals in Canada. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> For analysis, interpretive description was used as a methodology to understand clinical phenomena; hence, informing clinical applications. <h3>Results</h3> Three themes described factors influencing therapists' use of ABT and/or technology for SCI/D rehabilitation. 1) Factors that influence therapists' decision-making approach to ABT included therapist roles, site-specific dynamics and goal setting. 2) Therapist perceived individual factors included patient confidence, motivation, tolerance, mourning period, and self-advocacy. 3) ABT and equipment access noted logistical and invisible barriers, and how technology was used for ABT, showing wide variability of equipment and modes of use across sites. <h3>Conclusions</h3> In Canadian rehabilitation hospitals, use of ABT and/or technology for individuals with SCI/D is variable, depending on therapists' perceived understanding. Education about what ABT is and site-specific implementation strategies are needed. <h3>Author(s) Disclosures</h3> None.

Virtual care for prostate cancer survivorship: protocol for an evaluation of a nurse-led algorithm-enhanced virtual clinic implemented at five cancer centres across Canada

IntroductionProstate cancer (PCa) is the most common cancer in Canadian men. Current models of survivorship care are no longer adequate to address the chronic and complex survivorship needs of patients...

Implementation facilitation to introduce and support emergency department-initiated buprenorphine for opioid use disorder in high need, low resource settings: protocol for multi-site implementation-feasibility study

BackgroundFor many reasons, the emergency department (ED) is a critical venue to initiate OUD interventions. The prevailing culture of the ED has been that substance use disorders are non-emergent conditions better addressed outside the ED where resources are less constrained. This study, its rapid funding mechanism, and accelerated timeline originated out of the urgent need to learn whether ED-initiated buprenorphine (BUP) with referral for treatment of OUD is generalizable, as well as to develop strategies to facilitate its adoption across a variety of ED settings and under real-world conditions. It both complements and uses methods adapted from Project ED Health (CTN-0069), a Hybrid Type 3 implementation-effectiveness study of using Implementation Facilitation (IF) to integrate ED-initiated BUP and referral programs.MethodsED-CONNECT (CTN 0079) was a three-site implementation study exploring the feasibility, acceptability, and impact of introducing ED-initiated BUP in rural and urban settings with high-need, limited resources, and different staffing structures. We used a multi-faceted approach to develop, introduce and iteratively refine site-specific ED clinical protocols and implementation plans for opioid use disorder (OUD) screening, ED-initiated BUP, and referral for treatment. We employed a participatory action research approach and use mixed methods incorporating data derived from abstraction of medical records and administrative data, assessments of recruited ED patient-participants, and both qualitative and quantitative inquiry involving staff from the ED and community, patients, and other stakeholders.DiscussionThis study was designed to provide the necessary, time-sensitive understanding of how to identify OUD and initiate treatment with BUP in the EDs previously not providing ED-initiated BUP, in communities in which this intervention is most needed: high need, low resource settings.Trial registration: The study was prospectively registered on ClinicalTrials.gov (NCT03544112) on June 01, 2018: https://clinicaltrials.gov/ct2/show/NCT03544112.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation

BackgroundTobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review.ObjectiveThis study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics.MethodsThis is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation.ResultsClinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups.ConclusionsClinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients’ context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

A Systems Approach to Front-End Redesign With Rapid Triage Implementation.

The most common site for hospital sentinel events due to care delays, secondary to waiting and/or inefficient processes, occurs in the emergency department (ED). Decreasing patient length of stay in an ED is a key initiative for many hospitals in order to maximize both quality and efficiency. The purpose of this practice improvement project was to (1) standardize front-end processes across a 6-hospital health system, (2) move non-sorting-related clinical questions out of triage, and (3) improve door-to-triage and door-to-provider times. The project occurred within a 6-hospital East Coast health system. This was a continuous quality improvement initiative utilizing the Donabedian theoretical model, plus the DMAIC method, for process improvement. A system-wide performance work team was formed including ED leaders and staff; site-specific implementation teams were also formed. Rapid triage implementation was effective in producing statistically significant improvement in door-to-triage, door-to-provider, and ED length of stay for discharged patients at 3 of the 6 sites. Further performance improvement projects in this area are needed to better understand the generalizability of this process in other EDs. Furthermore, from a leadership perspective, additional investigation is needed into the cost savings as well as shared labor opportunities that may exist when policies and processes are standardized across a system's service line.

Estimation of soil loss using remote sensing and GIS-based universal soil loss equation in northern catchment of Lake Tana Sub-basin, Upper Blue Nile Basin, Northwest Ethiopia

BackgroundSoil erosion is one of the major environmental challenges and has a significant impact on potential land productivity and food security in many highland regions of Ethiopia. Quantifying and identifying the spatial patterns of soil erosion is important for management. The present study aims to estimate soil erosion by water in the Northern catchment of Lake Tana basin in the NW highlands of Ethiopia. The estimations are based on available data through the application of the Universal Soil Loss Equation integrated with Geographic Information System and remote sensing technologies. The study further explored the effects of land use and land cover, topography, soil erodibility, and drainage density on soil erosion rate in the catchment.ResultsThe total estimated soil loss in the catchment was 1,705,370 tons per year and the mean erosion rate was 37.89 t ha−1 year−1, with a standard deviation of 59.2 t ha−1 year−1. The average annual soil erosion rare for the sub-catchments Derma, Megech, Gumara, Garno, and Gabi Kura were estimated at 46.8, 40.9, 30.9, 30.0, and 29.7 t ha−1 year−1, respectively. Based on estimated erosion rates in the catchment, the grid cells were divided into five different erosion severity classes: very low, low, moderate, high and extreme. The soil erosion severity map showed about 58.9% of the area was in very low erosion potential (0–1 t ha−1 year−1) that contributes only 1.1% of the total soil loss, while 12.4% of the areas (36,617 ha) were in high and extreme erosion potential with erosion rates of 10 t ha−1 year−1 or more that contributed about 82.1% of the total soil loss in the catchment which should be a high priority. Areas with high to extreme erosion severity classes were mostly found in Megech, Gumero and Garno sub-catchments. Results of Multiple linear regression analysis showed a relationship between soil erosion rate (A) and USLE factors that soil erosion rate was most sensitive to the topographic factor (LS) followed by the support practice (P), soil erodibility (K), crop management (C) and rainfall erosivity factor (R). Barenland showed the most severe erosion, followed by croplands and plantation forests in the catchment.ConclusionsUse of the erosion severity classes coupled with various individual factors can help to understand the primary processes affecting erosion and spatial patterns in the catchment. This could be used for the site-specific implementation of effective soil conservation practices and land use plans targeted in erosion-prone locations to control soil erosion.

A spatial model for nutrient mitigation potential of blue mussel farms in the western Baltic Sea

Worldwide, coastal and marine policies are increasingly aiming for environmental protection, and eutrophication is a global challenge, particularly impairing near-coastal marine water bodies. In this context, mussel mitigation aquaculture is currently considered an effective tool to extract nutrients from such water bodies. Mussel mitigation farming using longline systems with loops of collector material is a well-developed technology and considered promising in the western Baltic Sea. Besides several spatially limited field studies, a suitable spatial model for site-specific implementation is still lacking. In this study, we present a modular spatial model, consisting of a spatial and temporal habitat factor model (Module 1), blue mussel growth model (Module 2), mussel farm model (Module 3), and an avoidance of food limitation model (Module 4). The modules integrate data from in situ monitoring, mussel growth experiments, and eco-physiological modelling for the western Baltic Sea, to estimate spatially explicit nutrient reduction potentials. The model is flexible with respect to farm setups and harvest times and considers natural variability, model uncertainty, and required hydrodynamics. Modelling results proved valid at all scales and modules, and point out key areas for efficient mussel mitigation farms in Danish, German and Swedish areas. Modelled long-term mean mitigation potentials for harvest in November reach up to 0.88 tN/ha and 0.05 tP/ha for a farm setup using 2 m depth-range of the water column and 3.0 tN/ha and 0.17 tP/ha using up to 8 m, respectively. For Danish water bodies, we demonstrate that in efficient areas, mitigation farms (18.8 ha, 90 km collector substrate in loops with 2 m depth-range) required <3.6% of the space to extract the target nitrogen loads for good ecological status. The developed approach could prove valuable for implementing environmental policies in aquatic systems, e.g. in situ nutrient mitigation, aquaculture spatial planning, and habitat suitability mapping.

Standardizing congenital diaphragmatic hernia care in Canada: Implementing national clinical practice guidelines

PurposeWe sought to identify implementation barriers and opportunities to increase utilization of the Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative's clinical practice guideline. MethodsA validated readiness assessment was sent via SurveyMonkey™ to CAPSNet site coordinators and local CDH stakeholders. The survey was open from 11/2018 to 02/2019. Data and responses were analyzed using descriptive statistics (REB 2019-4753). ResultsEighty-six responses were received, of which 65% (n = 56/86) were fully completed. The greatest number of responses came from neonatology (n = 27), pediatric surgery (n = 25), and respiratory therapy (n = 10). Seventy-eight percent (n = 67/86) of respondents were aware of the CDH guideline, and 63% (n = 54/86) used the entire guideline, while 23% (n = 20/86) used only certain sections. Besides recommendations pertaining to fetal intervention and ECLS, interdisciplinary long-term surveillance and prenatal diagnosis were considered most difficult to implement owing to funding limitations. Most respondents (n = 49/56; 87.5%) felt they could implement >75% of the recommendations. Establishing common team goals [i.e., minimize care variations] (n = 33/58;57%), provider buy-in [commitment of all health professionals to the guideline] (n = 28/58;48%), and regular compliance assessment (n = 23/58;40%) would increase uptake. ConclusionThere is national awareness of the CDH guideline. Implementation strategies ensuring common team goals, provider buy-in, and regular compliance assessment should increase guideline uptake/utilization. Consolidating funding for interdisciplinary long-term surveillance and prenatal diagnosis is necessary for any site-specific implementation strategy. Level of evidenceLevel 4 qualitative, survey.

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention.

We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention. The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment. This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.

Importance of Remotely-Sensed Vegetation Variables for Predicting the Spatial Distribution of African Citrus Triozid (Trioza erytreae) in Kenya

Citrus is considered one of the most important fruit crops globally due to its contribution to food and nutritional security. However, the production of citrus has recently been in decline due to many biological, environmental, and socio-economic constraints. Amongst the biological ones, pests and diseases play a major role in threatening citrus quantity and quality. The most damaging disease in Kenya, is the African citrus greening disease (ACGD) or Huanglongbing (HLB) which is transmitted by the African citrus triozid (ACT), Trioza erytreae. HLB in Kenya is reported to have had the greatest impact on citrus production in the highlands, causing yield losses of 25% to 100%. This study aimed at predicting the occurrence of ACT using an ecological habitat suitability modeling approach. Specifically, we tested the contribution of vegetation phenological variables derived from remotely-sensed (RS) data combined with bio-climatic and topographical variables (BCL) to accurately predict the distribution of ACT in citrus-growing areas in Kenya. A MaxEnt (maximum entropy) suitability modeling approach was used on ACT presence-only data. Forty-seven (47) ACT observations were collected while 23 BCL and 12 RS covariates were used as predictor variables in the MaxEnt modeling. The BCL variables were extracted from the WorldClim data set, while the RS variables were predicted from vegetation phenological time-series data (spanning the years 2014–2016) and annually-summed land surface temperature (LST) metrics (2014–2016). We developed two MaxEnt models; one including both the BCL and the RS variables (BCL-RS) and another with only the BCL variables. Further, we tested the relationship between ACT habitat suitability and the surrounding land use/land cover (LULC) proportions using a random forest regression model. The results showed that the combined BCL-RS model predicted the distribution and habitat suitability for ACT better than the BCL-only model. The overall accuracy for the BCL-RS model result was 92% (true skills statistic: TSS = 0.83), whereas the BCL-only model had an accuracy of 85% (TSS = 0.57). Also, the results revealed that the proportion of shrub cover surrounding citrus orchards positively influenced the suitability probability of the ACT. These results provide a resourceful tool for precise, timely, and site-specific implementation of ACGD control strategies.

Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts

BackgroundSystematic screening of all colorectal tumors for Lynch Syndrome (LS) has been recommended since 2009. Currently, implementation of LS screening in healthcare systems remains variable, likely because LS screening involves the complex coordination of multiple departments and individuals across the healthcare system. Our specific aims are to (1) describe variation in LS screening implementation across multiple healthcare systems; (2) identify conditions associated with both practice variation and optimal implementation; (3) determine the relative effectiveness, efficiency, and costs of different LS screening protocols by healthcare system; and (4) develop and test in a real-world setting an organizational toolkit for LS screening program implementation and improvement. This toolkit will promote effective implementation of LS screening in various complex health systems.MethodsThis study includes eight healthcare systems with 22 clinical sites at varied stages of implementing LS screening programs. Guided by the Consolidated Framework for Implementation Research (CFIR), we will conduct in-depth semi-structured interviews with patients and organizational stakeholders and perform economic evaluation of site-specific implementation costs. These processes will result in a comprehensive cross-case analysis of different organizational contexts. We will utilize qualitative data analysis and configurational comparative methodology to identify facilitators and barriers at the organizational level that are minimally sufficient and necessary for optimal LS screening implementation.DiscussionThe overarching goal of this project is to combine our data with theories and tools from implementation science to create an organizational toolkit to facilitate implementation of LS screening in various real-world settings. Our organizational toolkit will account for issues of complex coordination of care involving multiple stakeholders to enhance implementation, sustainability, and ongoing improvement of evidence-based LS screening programs. Successful implementation of such programs will ultimately reduce suffering of patients and their family members from preventable cancers, decrease waste in healthcare system costs, and inform strategies to facilitate the promise of precision medicine.Trial registrationN/A

Navigating Complex Implementation Contexts: Overcoming Barriers and Achieving Outcomes in a National Initiative to Scale Out Housing First in Canada

The scaling out of Housing First (HF) programs was examined in six Canadian communities, in which a multi-component HF training and technical assistance (TTA) was provided. Three research questions were addressed: (a) What were the outcomes of the TTA in terms of the development of new, sustained, or enhanced programs, and fidelity to the HF model? (b) How did the TTA contribute to implementation and fidelity? and (c) What contextual factors facilitated or challenged implementation and fidelity? A total of 14 new HF programs were created, and nine HF programs were sustained or enhanced. Fidelity assessments for 10 HF programs revealed an average score of 3.3/4, which compares favorably with other HF programs during early implementation. The TTA influenced fidelity by addressing misconceptions about the model, encouraging team-based practice, and facilitating case-based dialogue on site specific implementation challenges. The findings were discussed in terms of the importance of TTA for enhancing the capacities of the HF service delivery system-practitioners, teams, and communities-while respecting complex community contexts, including differences in policy climate across sites. Policy climate surrounding accessibility of housing subsidies, and use of Assertive Community Treatment teams (vs. Intensive Case Management) were two key implementation issues.