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Noar AP, Jeffery HE, Subbiah Ponniah H, Jaffer U. The aims and effectiveness of communities of practice in healthcare: A systematic review. PLoS One 2023; 18:e0292343. [PMID: 37815986 PMCID: PMC10564133 DOI: 10.1371/journal.pone.0292343] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/18/2023] [Indexed: 10/12/2023] Open
Abstract
Communities of practice (CoPs) are defined as "groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis". They are an effective form of knowledge management that have been successfully used in the business sector and increasingly so in healthcare. In May 2023 the electronic databases MEDLINE and EMBASE were systematically searched for primary research studies on CoPs published between 1st January 1950 and 31st December 2022. PRISMA guidelines were followed. The following search terms were used: community/communities of practice AND (healthcare OR medicine OR patient/s). The database search picked up 2009 studies for screening. Of these, 50 papers met the inclusion criteria. The most common aim of CoPs was to directly improve a clinical outcome, with 19 studies aiming to achieve this. In terms of outcomes, qualitative outcomes were the most common measure used in 21 studies. Only 11 of the studies with a quantitative element had the appropriate statistical methodology to report significance. Of the 9 studies that showed a statistically significant effect, 5 showed improvements in hospital-based provision of services such as discharge planning or rehabilitation services. 2 of the studies showed improvements in primary-care, such as management of hepatitis C, and 2 studies showed improvements in direct clinical outcomes, such as central line infections. CoPs in healthcare are aimed at improving clinical outcomes and have been shown to be effective. There is still progress to be made and a need for further studies with more rigorous methodologies, such as RCTs, to provide further support of the causality of CoPs on outcomes.
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Affiliation(s)
- Alexander P. Noar
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- Highgate Mental Health Centre, Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - Hannah E. Jeffery
- Department of General Surgery, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Hariharan Subbiah Ponniah
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Usman Jaffer
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
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McNett M, O'Mathúna D, Tucker S, Roberts H, Mion LC, Balas MC. A Scoping Review of Implementation Science in Adult Critical Care Settings. Crit Care Explor 2020; 2:e0301. [PMID: 33354675 PMCID: PMC7746210 DOI: 10.1097/cce.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES A librarian-assisted search was performed using three electronic databases. STUDY SELECTION Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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Affiliation(s)
- Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Dónal O'Mathúna
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Sharon Tucker
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Haley Roberts
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
| | - Michele C Balas
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
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Fingrut W, Beck LA, Lo D. Oncology communities of practice: insights from a qualitative analysis. Curr Oncol 2018; 25:378-383. [PMID: 30607112 PMCID: PMC6291282 DOI: 10.3747/co.25.4088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background A community of practice (cop) is formally defined as a group of people who share a concern or a passion for something they do and who learn how to do it better as they interact regularly. Communities of practice represent a promising approach for improving cancer care outcomes. However, little research is available to guide the development of oncology cops. In 2015, our urban community hospital launched an oncology cop, with the goals of decreasing barriers to access, fostering collaboration, and improving practitioner knowledge of guidelines and services in cancer care. Here, we share insights from a qualitative analysis of feedback from participants in our cop. The objective of the project was to identify participant perspectives about preferred cop features, with a view to improving the quality of our community hospital's oncology cop. Methods After 5 in-person meetings of our oncology cop, participants were surveyed about what the cop should start, stop, and continue doing. Qualitative methods were used to analyze the feedback. Results The survey collected 250 comments from 117 unique cop participants, including family physicians, specialist physicians, nurses, and allied health care practitioners. Analysis identified participant perspectives about the key features of the cop and avenues for improvement across four themes: supporting knowledge exchange, identifying and addressing practice gaps, enhancing interprofessional collaboration, and fostering a culture of partnership. Conclusions Based on the results, we identified several considerations that could be helpful in improving our cop. Our findings might help guide the development of oncology cops at other institutions.
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Affiliation(s)
- W Fingrut
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - L A Beck
- Faculty of Medicine, University of Toronto, Toronto, ON
- Division of Hematology and Oncology, St. Joseph's Health Centre, Toronto, ON
| | - D Lo
- Faculty of Medicine, University of Toronto, Toronto, ON
- Division of Hematology and Oncology, St. Joseph's Health Centre, Toronto, ON
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Fingrut W, Beck LA, Lo D. Building an oncology community of practice to improve cancer care. ACTA ACUST UNITED AC 2018; 25:371-377. [PMID: 30607111 DOI: 10.3747/co.25.4087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Communities of practice (cops) have been shown to be effective models for achieving quality outcomes in health care. Objective Here, we describe the application of the cop model to the Canadian oncology context. Methods We established an oncology cop at our urban community hospital and its networks. Goals were to decrease barriers to access, foster collaboration, and improve knowledge of guidelines in cancer care. We hosted 6 in-person multidisciplinary meetings, focusing on screening, diagnosis, and management of common solid tumours. Health care providers affiliated with our hospital were invited to attend and to complete post-meeting surveys. Likert scales assessed whether cop goals were realized. Results Meetings attracted a mean of 57 attendees (range: 48-65 attendees), with a mean of 84% completing the surveys and consenting to the analysis. Attendees included family physicians (mean: 41%), specialist physicians (mean: 24%), nurses (mean: 10%), and allied health care providers (mean: 22%). Repeat attendance increased during the series, with 85% of attendees at the final meeting having attended 1 or more prior meetings. Across the series, most participants agreed or strongly agreed that the cop reduced barriers (mean: 76.0% ± 7.9%) and improved access to cancer care services (mean: 82.4% ± 8.1%) and subject matter experts (mean: 91.7% ± 4.2%); fostered teamwork (mean: 84.5% ± 6.8%) and a culture of collaboration (mean: 94.8% ± 4.2%); improved knowledge of cancer care services (mean: 93.3% ± 4.8%), standards of practice (mean: 92.3% ± 3.1%), and quality indicators (mean: 77.5% ± 6.3%); and improved cancer-related practice (mean: 88.8% ± 4.6%) and satisfaction in caring for cancer patients (mean: 82.9% ± 6.8%). Participant feedback carried a potential for bias. Conclusions We demonstrated the feasibility of oncology cops and found that participants perceived their value in reducing barriers to access, fostering collaboration, and improving knowledge of guidelines in cancer care.
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Affiliation(s)
- W Fingrut
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - L A Beck
- Faculty of Medicine, University of Toronto, Toronto, ON.,Division of Hematology and Oncology, St. Joseph's Health Centre, Toronto, ON
| | - D Lo
- Faculty of Medicine, University of Toronto, Toronto, ON.,Division of Hematology and Oncology, St. Joseph's Health Centre, Toronto, ON
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Drews FA, Bakdash JZ, Gleed JR. Improving central line maintenance to reduce central line-associated bloodstream infections. Am J Infect Control 2017; 45:1224-1230. [PMID: 28684127 DOI: 10.1016/j.ajic.2017.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A human factors engineering-based intervention aimed at the modification of task behavior to increase adherence to best practices and the reduction of central line-associated bloodstream infections (CLABSI). The hypothesis was tested that a central line maintenance kit would improve adherence and reduce CLABSI compared with a standard, nonkit-based method of performing central line maintenance. DESIGN The study design was a 29-month prospective, interventional, nonrandomized, observational, and clinical research study using a pre-post implementation assessment. SETTING The study was conducted at a tertiary hospital in the southwestern United States, with participants recruited from a total of 6 patient units (including intensive care units and general wards). PARTICIPANTS A total of 95 nurses and 151 patients volunteered to participate in the study. INTERVENTION A central line maintenance kit was developed that incorporated human factors engineering design principles. This kit was implemented hospitalwide during the clinical study to assess the intervention's influence on protocol adherence and clinical outcomes compared with a preimplementation control condition (no kit use). RESULTS The results of this clinical observations study suggest that a human factors engineering-based kit improved adherence to best practices during central line maintenance. In addition, the number of CLABSIs was significantly reduced during the postimplementation period. CONCLUSIONS The application of human factors engineering design principles in the development of medical kits can improve protocol adherence and clinical outcomes.
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Affiliation(s)
- Frank A Drews
- Salt Lake Informatics, Decision Enhancement, and Surveillance Center, VA Medical Center, Salt Lake City, UT; Department of Psychology, University of Utah, Salt Lake City, UT.
| | - Jonathan Z Bakdash
- Salt Lake Informatics, Decision Enhancement, and Surveillance Center, VA Medical Center, Salt Lake City, UT
| | - Jeremy R Gleed
- Salt Lake Informatics, Decision Enhancement, and Surveillance Center, VA Medical Center, Salt Lake City, UT
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Hsin HT, Hsu MS, Shieh JS. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Postgrad Med J 2016; 93:133-137. [PMID: 27474228 DOI: 10.1136/postgradmedj-2016-134261] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/02/2016] [Accepted: 07/04/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To address the importance of bundle care for catheter-related infection (CRBSI) on the basis of long-term observation in a catheter-abundant cardiovascular intensive care unit (CVICU). DESIGN Prospective longitudinal cohort study. SETTING CVICU of a tertiary referring medical centre in northern Taiwan. PARTICIPANTS Around 1400 critically ill patients annually for 5 years in the CVICU (from January 2010 to June 2015). CRBSI bundle care has been applied ever since by a multidisciplinary team. MAIN OUTCOME MEASURES CRBSI per 1000 catheter days, bloodstream infection (BSI) per 1000 inpatient days, and catheter utilisation rates. RESULTS From January 2010 to June 2015 (22 quarters), there were in total 45 140 inpatient days and 24 163 catheter days, with an overall central venous catheter utilisation rate of 53.5%. The duration of the indwelled catheter was 6.3±1.2 days. The beginning CRBSI rate was 7.0 per 1000 catheter days and was significantly decreased to 0.7 per 1000 catheter days (p<0.001). Regarding the time series, cubic polynomial function depicted the CRBSI decrement most vividly (R2=0.501, p=0.005). In addition, the improvement in overall BSIs (2010 Q1, 4.4 per 1000 inpatient days to 2015 Q2, 0.5 per 1000 inpatient days, p<0.001) significantly correlated with the decrease in CRBSI (r=0.86, p<0.001). CONCLUSIONS Through the bundle care, we successfully reduced CRBSIs. After 5 years of follow-up, we observed that the effect of bundle care was stepwise and persistent, as long as we kept working on this integrated project.
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Affiliation(s)
- Ho-Tsung Hsin
- Cardiovascular Intensive Care Unit, Far-Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Mechanical Engineering, Innovation Center for Big Data and Digital Convergence, Yuan Ze University, Tauyuan City, Taiwan
| | - Meng-Shiuan Hsu
- Division of Infectious Disease, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jiann-Shing Shieh
- Department of Mechanical Engineering, Innovation Center for Big Data and Digital Convergence, Yuan Ze University, Tauyuan City, Taiwan
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Lai NM, Lai NA, O'Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev 2016; 7:CD010140. [PMID: 27410189 PMCID: PMC6457952 DOI: 10.1002/14651858.cd010140.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs. OBJECTIVES To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities. SEARCH METHODS In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). MAIN RESULTS Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events. AUTHORS' CONCLUSIONS It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.
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Affiliation(s)
- Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
- Monash University MalaysiaSchool of PharmacySelangorMalaysia
| | - Nai An Lai
- Queen Elizabeth II Jubilee HospitalIntensive Care UnitCnr Troughton and Kessels RoadsCoopers PlainsQueenslandAustralia4108
| | - Elizabeth O'Riordan
- The University of Sydney and The Children's Hospital at WestmeadFaculty of Nursing and MidwiferySydneyNew South WalesAustralia2006
| | - Nathorn Chaiyakunapruk
- Monash University MalaysiaSchool of PharmacySelangorMalaysia
- Faculty of Pharmaceutical SciencesCenter of Pharmaceutical Outcomes Research, Department of Pharmacy PracticeNaresuan UniversityPhitsanulokThailand65000
- The University of QueenslandSchool of Population HealthBrisbaneQueenslandAustralia
| | - Jacqueline E Taylor
- Monash Medical Centre/Monash UniversityMonash Newborn246 Clayton RoadClaytonVictoriaAustralia3168
| | - Kenneth Tan
- Monash UniversityDepartment of Paediatrics246 Clayton RoadClaytonMelbourneVictoriaAustraliaVIC 3168
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Ista E, van der Hoven B, Kornelisse RF, van der Starre C, Vos MC, Boersma E, Helder OK. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2016; 16:724-734. [PMID: 26907734 DOI: 10.1016/s1473-3099(15)00409-0] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections. METHODS We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models. FINDINGS We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%). INTERPRETATION Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs. FUNDING None.
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Affiliation(s)
- Erwin Ista
- Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
| | | | - René F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Cynthia van der Starre
- Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands
| | - Eric Boersma
- Department of Cardiology, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam, Netherlands
| | - Onno K Helder
- Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Sheils M, Ross M, Eatough N, Caputo ND. Intraosseous access in trauma by air medical retrieval teams. Air Med J 2016; 33:161-4. [PMID: 25049187 DOI: 10.1016/j.amj.2014.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 03/06/2014] [Accepted: 03/13/2014] [Indexed: 10/25/2022]
Abstract
Trauma accounts for a significant portion of overall mortality globally. Hemorrhage is the second major cause of mortality in the prehospital environment. Air medical retrieval services throughout the world have been developed to help improve the outcomes of patients suffering from a broad range of medical conditions, including trauma. These services often utilize intraosseous (IO) devices as an alternative means for access of both medically ill and traumatically injured patients in austere environments. However, studies have suggested that IO access cannot reach acceptable rates for massive transfusion. We review the subject to find the answer of whether IO access should be performed by air medical teams in the prehospital setting, or would central venous (CVC) access be more appropriate? We decided to assess the literature for capacity of IO access to meet resuscitation requirements in the prehospital management of trauma. We also decided to compare the insertion and complication characteristics of IO and CVC access.
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Affiliation(s)
| | | | | | - Nicholas D Caputo
- CareFlight, Darwin, NT Australia; Department of Emergency Medicine, Lincoln Medical and Mental Health Center Bronx, NY, USA.
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Kothari A, Boyko JA, Conklin J, Stolee P, Sibbald SL. Communities of practice for supporting health systems change: a missed opportunity. Health Res Policy Syst 2015. [PMID: 26208500 PMCID: PMC4515005 DOI: 10.1186/s12961-015-0023-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Communities of practice (CoPs) have been used in the health sector to support professional practice change. However, little is known about how CoPs might be used to influence a system that requires change at and across various levels (i.e. front line care, organizational, governmental). In this paper we examine the experience of a CoP in the Canadian province of Ontario as it engages in improving the care of seniors. Our aim is to shed light on using CoPs to facilitate systems change. METHODS This paper draws on year one findings of a larger multiple case study that is aiming to increase understanding of knowledge translation processes mobilized through CoPs. In this paper we strategically report on one case to illustrate a critical example of a CoP trying to effect systems change. Primary data included semi-structured interviews with CoP members (n = 8), field notes from five planning meetings, and relevant background documents. Data analysis included deductive coding (i.e. pre-determined codes aligned with the larger project) and inductive coding which allowed codes and themes to emerge. A thorough description of the case was prepared using all the coded data. RESULTS The CoP recognized a need to support health professionals (nurses, dentists) and related paraprofessionals with knowledge, experience, and resources to appropriately address their clients' oral health care needs. Accordingly, the CoP led a knowledge-to-action initiative that involved a seven-part webinar series meant to transfer step-by-step, skill-based knowledge through live and archived webinars. Although the core planning team functioned effectively to develop the webinars, the CoP was challenged by organizational and long-term care sector cultures, as well as governmental structures within the broader health context. CONCLUSION The provincial CoP functioned as an incubator that brought together best practices, research, experiences, a reflective learning cycle, and passionate champions. Nevertheless, the CoP's efforts to stimulate practice changes were met with broader resistance. Research about how to use CoPs to influence health systems change is needed given that CoPs are being tasked with this goal.
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Affiliation(s)
- Anita Kothari
- Western University, School of Health Studies and Schulich Interfaculty Program in Public Health, 1151 Richmond St, London, N6A 3K7, Canada.
| | - Jennifer A Boyko
- Western University, School of Health Studies and Faculty of Information and Media Studies, London, Canada.
| | - James Conklin
- Department of Applied Human Sciences and Élisabeth Bruyère Research Institute, Concordia University, Portland, USA.
| | - Paul Stolee
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Canada.
| | - Shannon L Sibbald
- Western University, School of Health Studies, Schulich Interfaculty Program in Public Health and Department of Family Medicine, London, Canada.
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Marang-van de Mheen PJ, van Bodegom-Vos L. Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf 2015; 25:118-29. [DOI: 10.1136/bmjqs-2014-003787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 07/01/2015] [Indexed: 11/04/2022]
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Simpson CD, Hawes J, James AG, Lee KS. Use of bundled interventions, including a checklist to promote compliance with aseptic technique, to reduce catheter-related bloodstream infections in the intensive care unit. Paediatr Child Health 2014; 19:e20-3. [PMID: 24855420 PMCID: PMC4028651 DOI: 10.1093/pch/19.4.e20] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A checklist that promotes compliance with aseptic technique during line insertion is a component of many care bundles aimed at reducing nosocomial infections among intensive care unit patients. OBJECTIVE To determine whether the use of bundled interventions that include a checklist during central-line insertions reduces catheter-related bloodstream infections in intensive care unit patients. METHODS A literature review was performed using methodology adapted from the American Heart Association's International Liaison Committee on Resuscitation. RESULTS Seventeen cohort studies were included. Thirteen studies were supportive of the intervention, while four were neutral. Infection rates ranged from 1.6 to 10.8 per 1000 central-line days in control groups, and from 0.0 to 3.8 per 1000 central-line days in the intervention groups. CONCLUSION There is fair evidence to recommend the use of care bundles that include a checklist during central-line insertion in intensive care unit patients to reduce the incidence of catheter-related bloodstream infections.
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Affiliation(s)
- C David Simpson
- Division of Neonatal-Perinatal Medicine, Dalhousie University, Halifax, Nova Scotia
- Department of Paediatrics, Dalhousie University, Halifax, Nova Scotia
| | - Judith Hawes
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Andrew G James
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Kyong-Soon Lee
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
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Bouza E, Guembe M, Pérez-Granda MJ. Innovative Strategies for Preventing Central-Line Associated Infections. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-013-0001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
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Schreiber JA. Beyond Evidence-Based Practice—Achieving Fundamental Changes in Research and Practice. Oncol Nurs Forum 2013; 40:208-10. [DOI: 10.1188/13.onf.208-210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Exline MC, Ali NA, Zikri N, Mangino JE, Torrence K, Vermillion B, St Clair J, Lustberg ME, Pancholi P, Sopirala MM. Beyond the bundle--journey of a tertiary care medical intensive care unit to zero central line-associated bloodstream infections. Crit Care 2013; 17:R41. [PMID: 23497591 PMCID: PMC3733431 DOI: 10.1186/cc12551] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/21/2012] [Accepted: 02/22/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION We set a goal to reduce the incidence rate of catheter-related bloodstream infections to rate of <1 per 1,000 central line days in a two-year period. METHODS This is an observational cohort study with historical controls in a 25-bed intensive care unit at a tertiary academic hospital. All patients admitted to the unit from January 2008 to December 2011 (31,931 patient days) were included. A multidisciplinary team consisting of hospital epidemiologist/infectious diseases physician, infection preventionist, unit physician and nursing leadership was convened. Interventions included: central line insertion checklist, demonstration of competencies for line maintenance and access, daily line necessity checklist, and quality rounds by nursing leadership, heightened staff accountability, follow-up surveillance by epidemiology with timely unit feedback and case reviews, and identification of noncompliance with evidence-based guidelines. Molecular epidemiologic investigation of a cluster of vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education for proper acquisition of blood cultures, environmental decontamination and daily chlorhexidine gluconate (CHG) bathing for patients. RESULTS Center for Disease Control/National Health Safety Network (CDC/NHSN) definition was used to measure central line-associated bloodstream infection (CLA-BSI) rates during the following time periods: baseline (January 2008 to December 2009), intervention year (IY) 1 (January to December 2010), and IY 2 (January to December 2011). Infection rates were as follows: baseline: 2.65 infections per 1,000 catheter days; IY1: 1.97 per 1,000 catheter days; the incidence rate ratio (IRR) was 0.74 (95% CI=0.37 to 1.65, P=0.398); residual seven CLA-BSIs during IY1 were VRE faecium blood cultures positive from central line alone in the setting of findings explicable by noninfectious conditions. Following staff education, environmental decontamination and CHG bathing (IY2): 0.53 per 1,000 catheter days; the IRR was 0.20 (95% CI=0.06 to 0.65, P=0.008) with 80% reduction compared to the baseline. Over the two-year intervention period, the overall rate decreased by 53% to 1.24 per 1,000 catheter-days (IRR of 0.47 (95% CI=0.25 to 0.88, P=0.019) with zero CLA-BSI for a total of 15 months. CONCLUSIONS Residual CLA-BSIs, despite strict adherence to central line bundle, may be related to blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition. Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary team approach focused on epidemiologic investigations of practitioner- or unit-specific etiologies.
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Affiliation(s)
- Matthew C Exline
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of
Internal Medicine, Ohio State University Wexner Medical Center, 201 Davis Heart
& Lung Research Institute, 473 West 12th Ave, Columbus, OH, 43210, USA
| | - Naeem A Ali
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of
Internal Medicine, Ohio State University Wexner Medical Center, 201 Davis Heart
& Lung Research Institute, 473 West 12th Ave, Columbus, OH, 43210, USA
| | - Nancy Zikri
- Department of Clinical Epidemiology, Ohio State University Wexner Medical Center,
410 West 10th Ave, Columbus, OH, 43210, USA
| | - Julie E Mangino
- Division of Infectious Diseases, Department of Internal Medicine, Department of
Clinical Epidemiology, Ohio State University Wexner Medical Center, 410 West 10th
Ave, Columbus, OH, 43210, USA
| | - Kelly Torrence
- Department of Nursing, Ohio State University Wexner Medical Center, 410 West 10th
Ave, Columbus, OH, 43210, USA
| | - Brenda Vermillion
- Department of Nursing, Ohio State University Wexner Medical Center, 410 West 10th
Ave, Columbus, OH, 43210, USA
| | - Jamie St Clair
- Department of Nursing, Ohio State University Wexner Medical Center, 410 West 10th
Ave, Columbus, OH, 43210, USA
| | - Mark E Lustberg
- Division of Infectious Diseases, Department of Internal Medicine, Ohio State
University Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA
| | - Preeti Pancholi
- Department of Pathology, Ohio State University Wexner Medical Center, 1492 East
Broad St Columbus, OH, 43205, USA
| | - Madhuri M Sopirala
- Division of Infectious Diseases, Department of Internal Medicine, Department of
Clinical Epidemiology, Ohio State University Wexner Medical Center, 410 West 10th
Ave, Columbus, OH, 43210, USA
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Intraosseous Vascular Access is Safe, Effective and Costs less than Central Venous Catheters for Patients in the Hospital Setting. J Vasc Access 2013; 14:216-24. [DOI: 10.5301/jva.5000130] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2012] [Indexed: 11/20/2022] Open
Abstract
Purpose Central venous catheters (CVCs) are often placed to resuscitate unstable emergency department (ED) patients. In an observational study, we assessed intraosseous (IO) vascular access in the hospital, and compared results to published experiences with CVC placement. Methods Patients who would typically receive a CVC were considered for the study. Vascular access was gained using a powered IO device. Data collection included placement success, placement time, ease-of-use, satisfaction with flow rates, complications and subsequent CVC placement. Results A total of 105 cases were studied from six centers. Mean age was 48.0±28.0 years and 53% were men; 85% of the patients were medical cases, and 53% were in cardiac/respiratory arrest. Of those, 48% returned to spontaneous circulation. A total of 94% of placements were successful on the first attempt. Mean time to IO access was 103.6±96.2 seconds. There was one serious complication – a lower extremity compartment syndrome. IO access costs $100/patient. Conclusions The data revealed faster and more successful IO catheter placement than reported for CVCs, few complications and high user satisfaction. For simple placements, cost savings for IO access vs. CVCs was $195/procedure. If 20% of the 3.5 million CVCs placed annually were replaced with IO catheters, cost savings could approach $650 million/year. We conclude that IO access in place of CVCs delivers high value in terms of being a safe, fast and effective mode of vascular access for patients in the hospital setting, with potentially substantial cost savings. These data indicate that IO access is a cost effective and viable alternative to problematic CVC lines.
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Secola R, Lewis MA, Pike N, Needleman J, Doering L. "Targeting to zero" in pediatric oncology: a review of central venous catheter-related bloodstream infections. J Pediatr Oncol Nurs 2012; 29:14-27. [PMID: 22367766 DOI: 10.1177/1043454211432752] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.
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Affiliation(s)
- Rita Secola
- Children's Hospital Los Angeles, CA 90027, USA.
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McPeake J, Cantwell S, Booth MG, Daniel M. Central line insertion bundle: experiences and challenges in an adult ICU. Nurs Crit Care 2012; 17:123-9. [PMID: 22497916 DOI: 10.1111/j.1478-5153.2012.00491.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central venous catheters are used frequently in the intensive care unit (ICU). However, there is an associated morbidity, mortality and cost derived from their infectious and mechanical complications. The Scottish Patient Safety Programme (SPSP) has developed a multi faceted care bundle, with the aim of reducing catheter-related blood stream infections. AIM This paper aims to identify and describe the experience and challenges in implementing the SPSP central line insertion bundle in one adult ICU, in a large inner city teaching hospital. INTERVENTIONS 'Plan-Do-Study-Act' cycles, checklists for insertion and a standardized trolley were adopted to implement the central line insertion bundle in clinical practice. CONCLUSION/IMPLICATIONS Improving the reliability of the central line insertion bundle has reduced infections. Key steps in the process were setting clear aims and ensuring staff understand the change process and measurement of results. This is fundamental to the success of any quality improvement process.
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Affiliation(s)
- Joanne McPeake
- Critical Care Unit, Glasgow Royal Infirmary, Glasgow, UK.
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Ranmuthugala G, Plumb JJ, Cunningham FC, Georgiou A, Westbrook JI, Braithwaite J. How and why are communities of practice established in the healthcare sector? A systematic review of the literature. BMC Health Serv Res 2011; 11:273. [PMID: 21999305 PMCID: PMC3219728 DOI: 10.1186/1472-6963-11-273] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 10/14/2011] [Indexed: 11/28/2022] Open
Abstract
Background Communities of Practice (CoPs) are promoted in the healthcare sector as a means of generating and sharing knowledge and improving organisational performance. However CoPs vary considerably in the way they are structured and operate in the sector. If CoPs are to be cultivated to benefit healthcare organisations, there is a need to examine and understand their application to date. To this end, a systematic review of the literature on CoPs was conducted, to examine how and why CoPs have been established and whether they have been shown to improve healthcare practice. Methods Peer-reviewed empirical research papers on CoPs in the healthcare sector were identified by searching electronic health-databases. Information on the purpose of establishing CoPs, their composition, methods by which members communicate and share information or knowledge, and research methods used to examine effectiveness was extracted and reviewed. Also examined was evidence of whether or not CoPs led to a change in healthcare practice. Results Thirty-one primary research papers and two systematic reviews were identified and reviewed in detail. There was a trend from descriptive to evaluative research. The focus of CoPs in earlier publications was on learning and exchanging information and knowledge, whereas in more recently published research, CoPs were used more as a tool to improve clinical practice and to facilitate the implementation of evidence-based practice. Means by which members communicated with each other varied, but in none of the primary research studies was the method of communication examined in terms of the CoP achieving its objectives. Researchers are increasing their efforts to assess the effectiveness of CoPs in healthcare, however the interventions have been complex and multifaceted, making it difficult to directly attribute the change to the CoP. Conclusions In keeping with Wenger and colleagues' description, CoPs in the healthcare sector vary in form and purpose. While researchers are increasing their efforts to examine the impact of CoPs in healthcare, cultivating CoPs to improve healthcare performance requires a greater understanding of how to establish and support CoPs to maximise their potential to improve healthcare.
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Affiliation(s)
- Geetha Ranmuthugala
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW 2052, Australia.
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Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control 2011; 39:640-646. [PMID: 21641088 DOI: 10.1016/j.ajic.2010.11.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 11/04/2010] [Accepted: 11/08/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Central venous lines (CVLs) are used extensively in intensive care units (ICUs) but can sometimes lead to catheter-related blood stream infections (CRBSIs). This study evaluated a "CVL bundle" to see whether the CRBSI rate would decrease, analyze any changes in the flora of CRBSIs, and project any decrease in health care costs. METHODS The CVL bundle was implemented on all patients admitted to the ICU starting January 2008. Data from CRBSI rates from 2006 and 2007 were pooled to compare the intervention. A Poisson analysis generated a relative risk reduction. Determination of costs were made by taking the excess length of stay multiplied by other costs (supplies, medications, cost of replacement of CVL) at our institution. RESULTS Overall infection rates decreased with an improvement in CRBSIs in all ICUs that participated. Although the proportion of gram-negative organisms did not change significantly, there was a decrease in the proportion of gram-positive infections (P = .05) and an increase in fungal infections (P = .04). The total excess cost per organism was determined by the following: total excess cost = excess length of stay + replacement of CVL + drug administration + antibiotic cost. The weighted excess cost took the total excess cost times a correction factor based on organism frequency. The total excess cost of any given CRBSI is approximately $32,254. CONCLUSION Preventing CRBSIs can improve patient care while reducing hospital stays, costs, and possible mortality. CVL bundles are fairly easy to perform with reproducible results.
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Affiliation(s)
- James S Kim
- USC Department of Infectious Diseases, USC and LAC Medical Center, Los Angeles, CA.
| | - Paul Holtom
- USC Department of Infectious Diseases, USC and LAC Medical Center, Los Angeles, CA; USC Department of Infection Control, USC and LAC Medical Center, Los Angeles, CA
| | - Cheryl Vigen
- Department of Biostatistics, Keck School of Medicine, Los Angeles, CA
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Ranmuthugala G, Cunningham FC, Plumb JJ, Long J, Georgiou A, Westbrook JI, Braithwaite J. A realist evaluation of the role of communities of practice in changing healthcare practice. Implement Sci 2011; 6:49. [PMID: 21600057 PMCID: PMC3120719 DOI: 10.1186/1748-5908-6-49] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 05/23/2011] [Indexed: 11/14/2022] Open
Abstract
Background Healthcare organisations seeking to manage knowledge and improve organisational performance are increasingly investing in communities of practice (CoPs). Such investments are being made in the absence of empirical evidence demonstrating the impact of CoPs in improving the delivery of healthcare. A realist evaluation is proposed to address this knowledge gap. Underpinned by the principle that outcomes are determined by the context in which an intervention is implemented, a realist evaluation is well suited to understand the role of CoPs in improving healthcare practice. By applying a realist approach, this study will explore the following questions: What outcomes do CoPs achieve in healthcare? Do these outcomes translate into improved practice in healthcare? What are the contexts and mechanisms by which CoPs improve healthcare? Methods The realist evaluation will be conducted by developing, testing, and refining theories on how, why, and when CoPs improve healthcare practice. When collecting data, context will be defined as the setting in which the CoP operates; mechanisms will be the factors and resources that the community offers to influence a change in behaviour or action; and outcomes will be defined as a change in behaviour or work practice that occurs as a result of accessing resources provided by the CoP. Discussion Realist evaluation is being used increasingly to study social interventions where context plays an important role in determining outcomes. This study further enhances the value of realist evaluations by incorporating a social network analysis component to quantify the structural context associated with CoPs. By identifying key mechanisms and contexts that optimise the effectiveness of CoPs, this study will contribute to creating a framework that will guide future establishment and evaluation of CoPs in healthcare.
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Affiliation(s)
- Geetha Ranmuthugala
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW 2052, Australia.
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Cherry MG, Brown JM, Neal T, Ben Shaw N. What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15. MEDICAL TEACHER 2010; 32:198-218. [PMID: 20218835 DOI: 10.3109/01421591003596600] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ). AIM This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers. METHODS We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention. RESULTS A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria. CONCLUSIONS Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.
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Malloy E, Butt S, Sorter M. Physician leadership and quality improvement in the acute child and adolescent psychiatric care setting. Child Adolesc Psychiatr Clin N Am 2010; 19:1-19; table of contents. [PMID: 19951803 DOI: 10.1016/j.chc.2009.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inpatient child and adolescent psychiatry leadership roles are often multifaceted, necessitating strong clinical knowledge and skills, organizational and leadership abilities, and in the academic setting the desire and skill in teaching and research. Early career psychiatrists who do possess these attributes may find themselves unprepared for such challenges as dealing with complex administrative and economic issues, accreditation, legal matters, and multitasking. This article offers a primer addressing these basic issues and in managing change through quality improvement processes.
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Affiliation(s)
- Erin Malloy
- Child and Adolescent Inpatient Services, Department of Psychiatry, University of North Carolina, Chapel Hill, NC 27599-7160, USA.
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Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009:CD000072. [PMID: 19588316 DOI: 10.1002/14651858.cd000072.pub2] [Citation(s) in RCA: 437] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Poor interprofessional collaboration (IPC) can negatively affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. OBJECTIVES To assess the impact of practice-based interventions designed to change IPC, compared to no intervention or to an alternate intervention, on one or more of the following primary outcomes: patient satisfaction and/or the effectiveness and efficiency of the health care provided. Secondary outcomes include the degree of IPC achieved. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2000-2007), MEDLINE (1950-2007) and CINAHL (1982-2007). We also handsearched the Journal of Interprofessional Care (1999 to 2007) and reference lists of the five included studies. SELECTION CRITERIA Randomised controlled trials of practice-based IPC interventions that reported changes in objectively-measured or self-reported (by use of a validated instrument) patient/client outcomes and/or health status outcomes and/or healthcare process outcomes and/or measures of IPC. DATA COLLECTION AND ANALYSIS At least two of the three reviewers independently assessed the eligibility of each potentially relevant study. One author extracted data from and assessed risk of bias of included studies, consulting with the other authors when necessary. A meta-analysis of study outcomes was not possible given the small number of included studies and their heterogeneity in relation to clinical settings, interventions and outcome measures. Consequently, we summarised the study data and presented the results in a narrative format. MAIN RESULTS Five studies met the inclusion criteria; two studies examined interprofessional rounds, two studies examined interprofessional meetings, and one study examined externally facilitated interprofessional audit. One study on daily interdisciplinary rounds in inpatient medical wards at an acute care hospital showed a positive impact on length of stay and total charges, but another study on daily interdisciplinary rounds in a community hospital telemetry ward found no impact on length of stay. Monthly multidisciplinary team meetings improved prescribing of psychotropic drugs in nursing homes. Videoconferencing compared to audioconferencing multidisciplinary case conferences showed mixed results; there was a decreased number of case conferences per patient and shorter length of treatment, but no differences in occasions of service or the length of the conference. There was also no difference between the groups in the number of communications between health professionals recorded in the notes. Multidisciplinary meetings with an external facilitator, who used strategies to encourage collaborative working, was associated with increased audit activity and reported improvements to care. AUTHORS' CONCLUSIONS In this updated review, we found five studies (four new studies) that met the inclusion criteria. The review suggests that practice-based IPC interventions can improve healthcare processes and outcomes, but due to the limitations in terms of the small number of studies, sample sizes, problems with conceptualising and measuring collaboration, and heterogeneity of interventions and settings, it is difficult to draw generalisable inferences about the key elements of IPC and its effectiveness. More rigorous, cluster randomised studies with an explicit focus on IPC and its measurement, are needed to provide better evidence of the impact of practice-based IPC interventions on professional practice and healthcare outcomes. These studies should include qualitative methods to provide insight into how the interventions affect collaboration and how improved collaboration contributes to changes in outcomes.
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Affiliation(s)
- Merrick Zwarenstein
- Continuing Education, University of Toronto, Senior Scientist, Institute for Clinical Evaluative Sciences, Room G1 06, 1075 Bayview Ave, Toronto, ON, Canada, M4N 3M5
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Curran E, Murdoch H. Aiming to reduce catheter associated urinary tract Infections (CAUTI) by adopting a checklist and bundle to achieve sustained system improvements. J Infect Prev 2009. [DOI: 10.1177/1757177408097755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Evonne Curran
- Health Protection Scotland, 1 Cadogan Square, Cadogan Street, Glasgow G2 7HF,
| | - Heather Murdoch
- Infection Control Team HAI & IC Group, NHS National Services Scotland, Cadogan House, 1 Cadogan Square, Glasgow G2 7HF
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Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. The CLABs Collaborative: A Regionwide Effort to Improve the Quality of Care in Hospitals. Jt Comm J Qual Patient Saf 2008; 34:713-23. [DOI: 10.1016/s1553-7250(08)34094-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
CRBSIs are expensive, prevalent, and often fatal complications. In the past few years, several preventive interventions have been applied with excellent results toward decreasing CRBSIs. Studies show that most CRBSIs are preventable; therefore, health care organizations should strive to substantially reduce if not eliminate them. In addition to being a measure of quality of care, reducing infections will soon be a bottom-line issue, given that the Centers for Medicare and Medicaid Services announced its decision to cease paying hospitals from October 2008 for some care necessitated by "preventable complications", including CRBSIs. Therefore, health care facilities that do not make the necessary adjustments to improve the quality of their patient care and avoid harm may be economically penalized. This article reviews the available evidence on and possible barriers to the widespread use of preventive strategies. The health care community has struggled to build a culture that can eliminate the barriers obstructing high-quality care. These new approaches must facilitate collaboration among caregivers. During the past few years, much effort has been dedicated to researching causes for inadequate patient care and executing interventions to improve processes of care; only now are projects beginning to focus on evaluating whether patients are safer. This article discusses the prevention of CRBSIs and shows that substantial reductions in the rate of these infections are possible. It is no longer acceptable for health care organizations to have the goal of being at the CDC mean for rate of infections; they should strive to substantially reduce or even eliminate them. Patients deserve no less.
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Affiliation(s)
- Jose M Rodriguez-Paz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, 297 Meyer, Baltimore, MD 21287, USA.
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Bonello RS, Fletcher CE, Becker WK, Clutter KL, Arjes SL, Cook JJ, Petzel RA. An Intensive Care Unit Quality Improvement Collaborative in Nine Department of Veterans Affairs Hospitals: Reducing Ventilator-Associated Pneumonia and Catheter-Related Bloodstream Infection Rates. Jt Comm J Qual Patient Saf 2008; 34:639-45. [DOI: 10.1016/s1553-7250(08)34081-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Berriel-Cass D, Adkins FW, Jones P, Fakih MG. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2007; 32:612-20. [PMID: 17120920 DOI: 10.1016/s1553-7250(06)32079-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Eliminating nosocomial infections was identified as one of eight priorities for action for Ascension Health. St. John Hospital and Medical Center (SJHMC), and St. Vincent's Hospital (STV), designated alpha sites, developed best practices for the prevention of catheter-related blood stream infections (CR-BSIs) and ventilator-associated pneumonia (VAP), respectively. METHODS Both hospitals used the Institute for Healthcare Improvement model of "bundles" to achieve the goal of reducing nosocomial infections and also implemented multidisciplinary rounds and the use of daily goal sheets in the intensive care unit (ICU). RESULTS Through the use of ventilator bundle, central line (CL) bundle, MDRs, and daily goal sheets, both facilities reduced CR-BSIs and VAPs by more than 50%. DISCUSSION SJHMC saw the benefit of having the physical presence of the ICPs in the ICUs, providing the staff with on-the-spot reinforcement of the initiative. STV found by starting the change process through the use of a flexible MDR team, the hospital was able to successfully implement positive changes in its ICU culture. On the basis of the success in the ICU, the concept of MDR teams eventually was adapted and spread to all units. Open communication among all patient caregivers was extended and served to provide improved patient care throughout the hospital.
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Brungs SM, Render ML. Using Evidence-Based Practice to Reduce Central Line Infections. Clin J Oncol Nurs 2007; 10:723-5. [PMID: 17193938 DOI: 10.1188/06.cjon.723-725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Suzanne M Brungs
- Veterans Affairs Inpatient Evaluation Center, Cincinnati VA Medical Center, Ohio, USA.
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