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Keenan EK. RE/UN/DIScover Heuristic: Working with Clinical Practice Impingements in Dehumanizing Times. CLINICAL SOCIAL WORK JOURNAL 2023:1-12. [PMID: 37360755 PMCID: PMC10158678 DOI: 10.1007/s10615-023-00872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Although clinical social work seeks to center the transformative potential of human relationships, practitioners are experiencing heightened systemic and organizational impingements from the dehumanizing pressures of neoliberalism. Neoliberalism and racism diminish the vitality and transformative potential of human relationships, disproportionately affecting Black, Indigenous and People of Color (BIPOC) communities. Practitioners are also experiencing increased stress and burnout related to increased caseloads and decreased professional autonomy and organizational practitioner support. Holistic, culturally responsive, and anti-oppressive processes seek to counter these oppressive forces but need further development to synthesize antioppressive structural understandings with embodied relational interactions. Practitioners can potentially contribute to efforts that apply critical theories and antioppressive understandings within their practice and workplace. Through an iterative flow of three sets of practices, the RE/UN/DIScover heuristic supports practitioners' efforts to respond in those challenging everyday moments where oppressive forms of power are imposed and embedded within systemic processes. With themselves and other colleagues, practitioners engage in compassionate REcover practices; use curious, critical reflection to UNcover full understandings of power dynamics, impacts, and meanings; and draw on creative courage to DIScover and enact socially just and humanizing responses. This paper describes how practitioners can use the RE/UN/DIScover heuristic in two common challenging moments of clinical practice: systemic practice impingements and implementing a new training or practice model. The heuristic seeks to support practitioners' efforts to preserve and expand socially just, relational spaces for themselves and those with whom they work within the context of systemic dehumanizing neoliberal forces.
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Affiliation(s)
- Elizabeth King Keenan
- Department of Social Work, Southern Connecticut State University, 101 Farnham Avenue, New Haven, CT 06515 USA
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2
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Mariano ER, Dickerson DM, Szokol JW, Harned M, Mueller JT, Philip BK, Baratta JL, Gulur P, Robles J, Schroeder KM, Wyatt KEK, Schwalb JM, Schwenk ES, Wardhan R, Kim TS, Higdon KK, Krishnan DG, Shilling AM, Schwartz G, Wiechmann L, Doan LV, Elkassabany NM, Yang SC, Muse IO, Eloy JD, Mehta V, Shah S, Johnson RL, Englesbe MJ, Kallen A, Mukkamala SB, Walton A, Buvanendran A. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2021; 47:118-127. [PMID: 34552003 DOI: 10.1136/rapm-2021-103083] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022]
Abstract
The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.
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Affiliation(s)
- Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Beverly K Philip
- American Society of Anesthesiologists, Schaumburg, Illinois, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Robles
- Department of Urology, Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richa Wardhan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Todd S Kim
- Department of Orthopedic Surgery, Palo Alto Medical Foundation, Burlingame, California, USA
| | - Kent K Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gary Schwartz
- AABP Integrative Pain Care, Brooklyn, New York, USA.,Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vikas Mehta
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Orange, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanda Kallen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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3
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Fischer M, Safaeinili N, Haverfield MC, Brown-Johnson CG, Zionts D, Zulman DM. Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework. J Gen Intern Med 2021; 36:1041-1048. [PMID: 33537952 PMCID: PMC8042058 DOI: 10.1007/s11606-020-06451-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/13/2020] [Indexed: 01/01/2023]
Abstract
Human-centered design (HCD), an empathy-driven approach to innovation that focuses on user needs, offers promise for the rapid design of health care interventions that are acceptable to patients, clinicians, and other stakeholders. Reviews of HCD in healthcare, however, note a need for greater rigor, suggesting an opportunity for integration of elements from traditional research and HCD. A strategy that combines HCD principles with evidence-grounded health services research (HSR) methods has the potential to strengthen the innovation process and outcomes. In this paper, we review the strengths and limitations of HCD and HSR methods for intervention design, and propose a novel Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) framework. AHEAD offers a practical guide for the design of creative, evidence-based, pragmatic solutions to modern healthcare challenges.
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Affiliation(s)
- Meredith Fischer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Nadia Safaeinili
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Marie C Haverfield
- Department of Communication Studies, San José State University, San Jose, CA, USA
| | - Cati G Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Dani Zionts
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Donna M Zulman
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Medicine, Stanford University, Stanford, CA, USA.
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Jones KJ, Skinner A, Venema D, Crowe J, High R, Kennel V, Allen J, Reiter‐Palmon R. Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals. Health Serv Res 2019; 54:994-1006. [PMID: 31215029 PMCID: PMC6736913 DOI: 10.1111/1475-6773.13186] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. DATA SOURCES/STUDY SETTING Fall-risk-reduction process and outcome measures from 16 small rural hospitals participating in a research demonstration and dissemination study from August 2012 to July 2014. Previously, these hospitals lacked a fall-event reporting system to drive improvement. STUDY DESIGN A one-group pretest-posttest embedded in a participatory research framework. We required hospitals to implement MTSs, which we supported by conducting education, developing an online toolkit, and establishing a fall-event reporting system. DATA COLLECTION Hospitals used gap analyses to assess the presence of fall-risk-reduction processes at study beginning and their frequency and effectiveness at study end; they reported fall-event data throughout the study. PRINCIPAL FINDINGS The extent to which hospitals implemented 21 processes to coordinate the fall-risk-reduction program and trained staff specifically about the program predicted unassisted and injurious fall rates during the end-of-study period (January 2014-July 2014). Bedside fall-risk-reduction processes were not significant predictors of these outcomes. CONCLUSIONS Multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.
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Affiliation(s)
- Katherine J. Jones
- College of Allied Health ProfessionsUniversity of Nebraska Medical CenterOmahaNebraska
| | - Anne Skinner
- College of Allied Health ProfessionsUniversity of Nebraska Medical CenterOmahaNebraska
| | - Dawn Venema
- College of Allied Health ProfessionsUniversity of Nebraska Medical CenterOmahaNebraska
| | - John Crowe
- Department of PsychologyUniversity of Nebraska at OmahaOmahaNebraska
| | - Robin High
- College of Public HealthUniversity of Nebraska Medical CenterOmahaNebraska
| | - Victoria Kennel
- College of Allied Health ProfessionsUniversity of Nebraska Medical CenterOmahaNebraska
| | - Joseph Allen
- Department of PsychologyUniversity of Nebraska at OmahaOmahaNebraska
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Borsky AE, Flores EJ, Berliner E, Chang C, Umscheid CA, Chang SM. Next Steps in Improving Healthcare Value: AHRQ Evidence-based Practice Center Program-Applying the Knowledge to Practice to Data Cycle to Strengthen the Value of Patient Care. J Hosp Med 2019; 14:311-314. [PMID: 30794140 PMCID: PMC6609136 DOI: 10.12788/jhm.3157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022]
Abstract
For more than 20 years, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program has been identifying and synthesizing evidence to inform evidence-based healthcare. Recognizing that many healthcare settings continue to face challenges in disseminating and implementing evidence into practice, AHRQ's EPC program has also embarked on initiatives to facilitate the translation of evidence into practice and to measure and monitor how practice changes impact health outcomes. The program has structured its efforts around the three phases of the Learning Healthcare System cycle: knowledge, practice, and data. Here, we use a topic relevant to the field of hospital medicine-Clostridium difficile colitis prevention and treatment-as an exemplar of how the EPC program has used this framework to move evidence into practice and develop systems to facilitate continuous learning in healthcare systems.
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Affiliation(s)
- Amanda E Borsky
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
- Corresponding Author: Amanda E. Borsky, DrPH, MPP; E-mail: ; Telephone: 301-427-1602
| | - Emilia J Flores
- University of Pennsylvania Health System, Center for Evidence-based Practice, Philadelphia, Philadelphia
| | - Elise Berliner
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Christine Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Craig A Umscheid
- University of Chicago Medicine, Center for Healthcare Delivery Science and Innovation, Chicago, Illinois
| | - Stephanie M Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
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Flores EJ, Mull NK, Lavenberg JG, Mitchell MD, Leas BF, Williams A, Brennan PJ, Umscheid CA. Using a 10-step framework to support the implementation of an evidence-based clinical pathways programme. BMJ Qual Saf 2018; 28:476-485. [PMID: 30463885 DOI: 10.1136/bmjqs-2018-008454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/02/2018] [Accepted: 10/21/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Integration of evidence into practice is suboptimal. Clinical pathways, defined as multidisciplinary care plans, are a method for translating evidence into local settings and have been shown to improve the value of patient care. OBJECTIVE To describe the development of a clinical pathways programme across a large academic healthcare system. METHODS We use a 10-step framework (grounded in the Knowledge-to-Action framework and ADAPTE Collaboration methodology for guideline adaptation) to support pathway development and dissemination, including facilitating clinical owner and stakeholder engagement, developing pathway prototypes based on rapid reviews of the existing literature, developing tools for dissemination and impact assessment. We use a cloud-based technology platform (Dorsata, Washington, DC) to assist with development and dissemination across our geographically distributed care settings and providers. Content is viewable through desktop and mobile applications. We measured programme adoption and penetration by examining number of pathways developed as well as mobile application use and pathway views. RESULTS From 1 February 2016 to 30 April 2018, a total of 202 pathways were disseminated. The three most common clinical domains represented were oncology (46.5%, n=94), pulmonary/critical care (8.9%, n=18) and cardiovascular medicine (7.4%, n=15). Users opting to register for a personal account totalled 1279; the three largest groups were physicians (45.1%, n=504), advanced practice providers (19.5%, n=245) and nurses (19.1%, n=240). Pathway views reached an average of 2150 monthly views during the last 3 months of the period. The majority of pathways reference at least one evidence-based source (93.6%, n=180). CONCLUSIONS A healthcare system can successfully use a framework and technology platform to support the development and dissemination of pathways across a multisite institution.
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Affiliation(s)
- Emilia J Flores
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA .,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikhil K Mull
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julia G Lavenberg
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Matthew D Mitchell
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Brian F Leas
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Austin Williams
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Patrick J Brennan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig A Umscheid
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jayakumar KL, Lavenberg JA, Mitchell MD, Doshi JA, Leas B, Goldmann DR, Williams K, Brennan PJ, Umscheid CA. Evidence synthesis activities of a hospital evidence-based practice center and impact on hospital decision making. J Hosp Med 2016; 11:185-92. [PMID: 26505618 DOI: 10.1002/jhm.2498] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 09/18/2015] [Accepted: 09/26/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hospital evidence-based practice centers (EPCs) synthesize and disseminate evidence locally, but their impact on institutional decision making is unclear. OBJECTIVE To assess the evidence synthesis activities and impact of a hospital EPC serving a large academic healthcare system. DESIGN, SETTING, AND PARTICIPANTS Descriptive analysis of the EPC's database of rapid systematic reviews since EPC inception (July 2006-June 2014), and survey of report requestors from the EPC's last 4 fiscal years. MEASUREMENTS Descriptive analyses examined requestor and report characteristics; questionnaire examined report usability, impact, and requestor satisfaction (higher scores on 5-point Likert scales reflected greater agreement). RESULTS The EPC completed 249 evidence reviews since inception. The most common requestors were clinical departments (29%, n = 72), chief medical officers (19%, n = 47), and purchasing committees (14%, n = 35). The most common technologies reviewed were drugs (24%, n = 60), devices (19%, n = 48), and care processes (12%, n = 31). Mean report completion time was 70 days. Thirty reports (12%) informed computerized decision support interventions. More than half of reports (56%, n = 139) were completed in the last 4 fiscal years for 65 requestors. Of the 64 eligible participants, 46 responded (72%). Requestors were satisfied with the report (mean = 4.4), and agreed it was delivered promptly (mean = 4.4), answered the questions posed (mean = 4.3), and informed their final decision (mean = 4.1). CONCLUSIONS This is the first examination of evidence synthesis activities by a hospital EPC in the United States. Our findings suggest hospital EPCs can efficiently synthesize and disseminate evidence addressing a range of clinical topics for diverse stakeholders, and can influence local decision making.
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Affiliation(s)
- Kishore L Jayakumar
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Julia A Lavenberg
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Matthew D Mitchell
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jalpa A Doshi
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Leas
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - David R Goldmann
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kendal Williams
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Patrick J Brennan
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Craig A Umscheid
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Institute for Biomedical Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
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Barker AL, Morello RT, Wolfe R, Brand CA, Haines TP, Hill KD, Brauer SG, Botti M, Cumming RG, Livingston PM, Sherrington C, Zavarsek S, Lindley RI, Kamar J. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ 2016; 352:h6781. [PMID: 26813674 PMCID: PMC4727091 DOI: 10.1136/bmj.h6781] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards. DESIGN Cluster randomised controlled trial. SETTING Six Australian hospitals. PARTICIPANTS All patients admitted to 24 acute wards during the trial period. INTERVENTIONS Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: "falls alert" sign, supervision of patients in the bathroom, ensuring patients' walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm. MAIN OUTCOME MEASURES The co-primary outcomes were falls and fall injuries per 1000 occupied bed days. RESULTS During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients' characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27; P=0.766) were similar in intervention and control wards. CONCLUSIONS Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12611000332921.
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Affiliation(s)
- Anna L Barker
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Renata T Morello
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Caroline A Brand
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Terry P Haines
- Physiotherapy Department, Monash University, Allied Health Research Unit, Monash Health, Kingston Centre, Cheltenham, VIC 3195, Australia
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA 6102, Australia
| | - Sandra G Brauer
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD 4072, Australia
| | - Mari Botti
- School of Nursing and Midwifery, Deakin University, Burwood, VIC 3125, Australia
| | - Robert G Cumming
- School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
| | | | - Catherine Sherrington
- George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
| | - Silva Zavarsek
- Centre for Health Economics, Monash Business School, Monash University, Clayton, VIC 3800, Australia
| | - Richard I Lindley
- George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
| | - Jeannette Kamar
- Northern Hospital, Northern Health, Epping, VIC 3076, Australia
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