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Robertson T, Borland ML, O'Brien S, Haskell L, Babl FE, Dalziel SR, Tavender E. Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies. Acta Paediatr 2024; 113:802-811. [PMID: 38189212 DOI: 10.1111/apa.17090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/10/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
AIM To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.
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Affiliation(s)
- Tim Robertson
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Meredith L Borland
- Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Western Australia, Australia
| | - Sharon O'Brien
- Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Libby Haskell
- Starship Children's Hospital, Auckland, New Zealand
- Departments Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Royal Children's Hospital, Parkville, Victoria, Australia
- Departments of Paediatrics and Critical Care, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Stuart R Dalziel
- Starship Children's Hospital, Auckland, New Zealand
- Cure Kids Chair of Child Health Research, Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia
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Lawrence J, Hiscock H, Voskoboynik A, Walpola R, Sharma A. Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis. J Paediatr Child Health 2024; 60:100-106. [PMID: 38597355 DOI: 10.1111/jpc.16539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/25/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024]
Abstract
AIM Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis. METHODS Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention. RESULTS Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for. CONCLUSIONS Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.
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Affiliation(s)
- Joanna Lawrence
- Hospital in the Home, Royal Children's Hospital, Melbourne, Victoria, Australia
- Health Services Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
| | - Harriet Hiscock
- Health Services Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Alice Voskoboynik
- Centre for Health Analytics, Melbourne Children's Campus, Melbourne, Victoria, Australia
| | - Ramesh Walpola
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
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Szymczak JE, Hayes AA, Labellarte P, Zighelboim J, Toor A, Becker AB, Gerber JS, Kuppermann N, Florin TA. Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia. Pediatrics 2024; 153:e2023063782. [PMID: 38234215 DOI: 10.1542/peds.2023-063782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ashley A Hayes
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Labellarte
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julian Zighelboim
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amandeep Toor
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam B Becker
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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4
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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5
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Ryan A, Swinburne C. Targeted interventions improve bronchiolitis care and reduce unnecessary therapies. Arch Dis Child Educ Pract Ed 2023; 108:143. [PMID: 35264440 DOI: 10.1136/archdischild-2021-323384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Aoife Ryan
- General Paediatrics, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Craig Swinburne
- Department of General Paediatrics, Royal Hospital for Children, Glasgow, UK
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Tavender EJ, Wilson CL, Dalziel S, Oakley E, Borland M, Ballard DW, Cotterell E, Phillips N, Babl FE. Qualitative study of emergency clinicians to inform a national guideline on the management of children with mild-to-moderate head injuries. Emerg Med J 2023; 40:195-199. [PMID: 36002242 DOI: 10.1136/emermed-2021-212198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 08/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Head injury is a common reason children present to EDs. Guideline development to improve care for paediatric head injuries should target the information needs of ED clinicians and factors influencing its uptake. METHODS We conducted semi-structured qualitative interviews (November 2017-November 2018) with a stratified purposive sample of ED clinicians from across Australia and New Zealand. We identified clinician information needs, used the Theoretical Domains Framework (TDF) to explore factors influencing the use of head CT and clinical decision rules/guidelines in CT decision-making, and explored ways to improve guideline uptake. Two researchers coded the interview transcripts using thematic content analysis. RESULTS A total of 43 clinicians (28 doctors, 15 nurses), from 19 hospitals (5 tertiary, 8 suburban, 6 regional/rural) were interviewed. Clinicians sought guidance for scenarios including ED management of infants, children with underlying medical issues, delayed or representations and potential non-accidental injuries. Improvements to the quality and content of discharge communication and parental discussion materials were suggested. Known risks of radiation from head CTs has led to a culture of observation over use of CT in Australasia (TDF domain: beliefs about consequences). Formal and informal policies have resulted in senior clinicians making most head CT decisions in children (TDF domain: behavioural regulation). Senior clinicians consider their gestalt to be more accurate and outperform existing guidance (TDF domain: beliefs about capabilities), although they perceive guidelines as useful for training and supporting junior staff. Summaries, flow charts, publication in ED-specific journals and scripted training materials were suggestions to improve uptake. CONCLUSION Information needs of ED clinicians, factors influencing use of head CT in children with head injuries and the role of guidelines were identified. These findings informed the scope and implementation strategies for an Australasian guideline for mild-to-moderate head injuries in children.
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Affiliation(s)
- Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Departments of Surgery and Paediatrics, University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith Borland
- Emergency Department, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatrics and Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Dustin W Ballard
- CREST Network & Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, Tablelands Clinical School, University of New England, Armidale, New South Wales, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia .,Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
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7
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Biagi C, Betti L, Manieri E, Dondi A, Pierantoni L, Ramanathan R, Zama D, Gennari M, Lanari M. Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study. Life (Basel) 2023; 13:life13030635. [PMID: 36983790 PMCID: PMC10056632 DOI: 10.3390/life13030635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.
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Affiliation(s)
- Carlotta Biagi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: (C.B.); (L.B.)
| | - Ludovica Betti
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
- Correspondence: (C.B.); (L.B.)
| | - Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ramsiya Ramanathan
- Infectious Diseases Unit, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Daniele Zama
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Monia Gennari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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8
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O’Brien SL, Haskell L, Tavender EJ, Wilson S, Borland ML, Oakley E, Dalziel SR, Gill FJ. Factors influencing health professionals' use of high-flow nasal cannula therapy for infants with bronchiolitis - A qualitative study. Front Pediatr 2023; 11:1098577. [PMID: 37009298 PMCID: PMC10060553 DOI: 10.3389/fped.2023.1098577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Aim To explore the factors influencing the use of high-flow nasal cannula (HFNC) therapy for infants with bronchiolitis. Design Qualitative approach using semi-structured interviews. Methods The semi-structured interviews (face-to-face or virtual) were conducted between September 2020 and February 2021. Deductive content analysis was used to map key influencing factors for use of HFNC therapy to the Theoretical Domains Framework (TDF). Results Nineteen interviews were undertaken before reaching thematic saturation (7 nurses, 12 doctors) in emergency departments and paediatric wards from four purposively selected hospitals in Australia and New Zealand. Influencing factors were mapped to eight domains in the TDF with 21 themes identified. Main findings included: (1) Health professionals' expectations of HFNC therapy on patient deterioration, work of breathing and oxygenation; (2) Staff emotions relating to concern and anxiety about deterioration and "need to do something"; (3) Social influences from other health professionals and parents and (4) Environmental factors relating to logistics of care and patient transfer considerations. These factors, combined with the ready availability of HFNC equipment and health professionals having the required skills to administer the therapy, contributed to its initiation. Conclusion Individual/personal and contextual/environmental factors contribute to the use of HFNC therapy for infants with bronchiolitis. It is evident these influences contribute substantially to increased use, despite evidence-based guidelines recommending a more nuanced approach to this therapy. These findings will inform a targeted implementation intervention to promote evidence-based use of HFNC therapy in infants with bronchiolitis.
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Affiliation(s)
- Sharon L. O’Brien
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Correspondence: Sharon L. O’Brien sharon.o’
| | - Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Sally Wilson
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Ed Oakley
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Emergency Department, Royal Children’s Hospital, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Fenella J. Gill
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- enAble Institute, Curtin University, Bentley, WA, Australia
- Nursing Research, Perth Children’s Hospital, Child & Adolescent Health Service, Nedlands, WA, Australia
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9
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Lirette MP, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Florin TA, Babl FE, Dalziel S, Freedman S, Roland D, Lyttle MD, Schnadower D, Steele D, Fernandes RM, Stephens D, Kharbanda A, Johnson DW, Macias C, Benito J, Schuh S. International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study. BMJ Open 2022; 12:e059784. [PMID: 36600373 PMCID: PMC9730363 DOI: 10.1136/bmjopen-2021-059784] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days. DESIGN A secondary analysis of a retrospective cohort study. SETTING 38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal. PATIENTS Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013. OUTCOME MEASURES Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits. RESULTS 1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)). CONCLUSIONS Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.
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Affiliation(s)
- Marie-Pier Lirette
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Kuppermann
- The Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
- University of California Davis Health System, Sacramento, California, USA
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Todd Adam Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Franz E Babl
- Emergency Department, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne/The Royal Children's Hospital CICH, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Stephen Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Mark David Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dale Steele
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Derek Stephens
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - David W Johnson
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Charles Macias
- Division of Pediatric Emergency Medicine, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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10
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O'Brien S, Haskell L, Schembri R, Gill FJ, Wilson S, Borland ML, Oakley E, Dalziel SR. Prevalence of high flow nasal cannula therapy use for management of infants with bronchiolitis in Australia and New Zealand. J Paediatr Child Health 2022; 58:2230-2235. [PMID: 36066264 PMCID: PMC10947204 DOI: 10.1111/jpc.16199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/09/2022] [Accepted: 08/21/2022] [Indexed: 11/27/2022]
Abstract
AIM To determine the prevalence of high flow nasal cannula (HFNC) therapy in infants presenting to hospital in Australia and New Zealand with bronchiolitis over four bronchiolitis seasons. Secondary aims were to determine temporal trends in HFNC use, and associations between HFNC, hospital length of stay (LOS) and intensive care unit (ICU) admission. METHODS A planned sub-study of a multi-centre international cluster randomised controlled trial investigating knowledge translation strategies for a bi-national bronchiolitis guideline. Demographics, management and outcomes data were collected retrospectively for infants presenting with bronchiolitis to 26 hospitals between 1 May 2014 and 30 November 2017. Prevalence data are presented as absolute frequencies (95% confidence interval (CI)) with differences between groups for continuous and categorical variables analysed using linear and logistic regression, respectively. RESULTS 11 715 infants were included with 3392 (29.0%, 95% CI (28.1-29.8%)) receiving oxygen therapy; of whom 1817 (53.6%, 95% CI (51.9-55.3%)) received HFNC. Use of oxygen therapy did not change over the four bronchiolitis seasons (P = 0.12), while the proportion receiving HFNC increased (2014, 336/2587 (43.2%); 2017, 609/3720 (57.8%); P ≤ 0.001). Infants who received HFNC therapy were not substantially different to infants who received oxygen therapy without HFNC. HFNC use was associated with increases in both hospital LOS (P < 0.001) and ICU admissions (P < 0.001). CONCLUSION Use of HFNC therapy for infants with bronchiolitis increased over 4 years. Of those who received oxygen therapy, the majority received HFNC therapy without improvement in hospital LOS or ICU admissions. Strategies to guide appropriate HFNC use in infants with bronchiolitis are required.
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Affiliation(s)
- Sharon O'Brien
- Emergency DepartmentPerth Children's HospitalPerthWestern AustraliaAustralia
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand
- Department of Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand
| | - Rachel Schembri
- Clinical Epidemiology and BiostatisticsMelbourne Children's Trials Centre, Murdoch Children's Research InstituteMelbourneVictoriaAustralia
| | - Fenella J Gill
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
- Child & Adolescent Health ServicePerth Children's HospitalPerthWestern AustraliaAustralia
| | - Sally Wilson
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Meredith L Borland
- Emergency DepartmentPerth Children's HospitalPerthWestern AustraliaAustralia
- Divisions of Emergency Medicine and Paediatrics, School of MedicineUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Ed Oakley
- Emergency DepartmentRoyal Children's HospitalParkvilleVictoriaAustralia
- Emergency ResearchMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Departments of Paediatrics and Critical CareUniversity of MelbourneMelbourneVictoriaAustralia
| | - Stuart R Dalziel
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand
- Departments of Surgery and Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand
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11
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Ramsden V, Middleton S, McInnes E, Babl FE, Tavender E. Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction. Emerg Med Australas 2022; 34:670-674. [PMID: 35918063 DOI: 10.1111/1742-6723.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
Despite an increased focus on ways to improve implementation of evidence and de-implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting.
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Affiliation(s)
- Victoria Ramsden
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Midwifery and Health Sciences, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Elizabeth McInnes
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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12
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Tan E, Haskell L, Beck S, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments. J Paediatr Child Health 2022; 58:1847-1854. [PMID: 35869746 PMCID: PMC9796887 DOI: 10.1111/jpc.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/09/2022] [Accepted: 07/06/2022] [Indexed: 01/07/2023]
Abstract
AIM To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED. RESULTS About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources). CONCLUSIONS Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentsNorth Shore and Waitakere HospitalsAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical & Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
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13
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Ramsden V, Babl FE, Dalziel SR, Middleton S, Oakley E, Haskell L, Lithgow A, Orsini F, Schembri R, Wallace A, Wilson CL, McInnes E, Wilson PH, Tavender E. Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol. BMC Health Serv Res 2022; 22:1099. [PMID: 36038929 PMCID: PMC9423692 DOI: 10.1186/s12913-022-08450-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. Methods A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. Discussion This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. Trial registration Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
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Affiliation(s)
- Victoria Ramsden
- Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.,Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia.,St Vincent's Hospital, Level 5 DeLacy Building, Victoria Road, Darlinghurst, NSW, 2010, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Libby Haskell
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Anna Lithgow
- Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Northern Territory, 0810, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Alexandra Wallace
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Department of Paediatrics, Waikato Hospital, Selwyn St, Hamilton Central, Hamilton, 3204, New Zealand
| | - Catherine L Wilson
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia
| | - Peter H Wilson
- Australian Catholic University, Building 460, Level 8, 250 Victoria Parade, East Melbourne, Victoria, 3002, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia.
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14
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Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet 2022; 400:392-406. [PMID: 35785792 DOI: 10.1016/s0140-6736(22)01016-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/27/2022] [Accepted: 05/26/2022] [Indexed: 02/06/2023]
Abstract
Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.
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Affiliation(s)
- Stuart R Dalziel
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Libby Haskell
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; School of Nursing, Curtin University, Perth, WA, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia; Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
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15
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Haskell L, Tavender EJ, O'Brien S, Wilson CL, Borland ML, Cotterell E, Babl FE, Zannino D, Sheridan N, Oakley E, Dalziel SR. Can targeted interventions change the factors influencing variation in management of infants with bronchiolitis? A survey of Australian and New Zealand clinicians: A paediatric research in emergency departments international collaborative (PREDICT) study. J Paediatr Child Health 2022; 58:302-311. [PMID: 34498782 DOI: 10.1111/jpc.15710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to determine whether targeted interventions, proven to be effective at improving evidence-based bronchiolitis management, changed factors previously found to influence variation in bronchiolitis management. METHODS This survey assessed change in factors influencing clinicians' (nurses and doctors) bronchiolitis management at baseline and post-intervention in a cluster randomised controlled trial of targeted, theory-informed interventions aiming to de-implement non-evidence-based bronchiolitis management (no use of chest X-ray, salbutamol, antibiotics, glucocorticoids and adrenaline). Survey questions addressed previously identified factors influencing bronchiolitis management from six Theoretical Domains Framework domains (knowledge; skills; beliefs about consequences; social/professional role and identity; environmental context and resources; social influences). Data analysis was descriptive. RESULTS A total of 1958 surveys (baseline = 996; post-intervention = 962) were completed by clinicians from the emergency department and paediatric inpatient units from 26 hospitals (intervention = 13; control = 13). Targeted bronchiolitis interventions significantly increased knowledge of the Australasian Bronchiolitis Guideline (intervention clinicians = 74%, control = 39%, difference = 34.7%, 95% confidence interval (CI) = 25.6-43.8%), improved skills in diagnosing (intervention doctors = 89%, control = 76%, difference = 12.6%, 95% CI = 6.2-19%) and managing bronchiolitis (intervention doctors = 87%, control = 76%, difference = 9.9%, 95% CI = 3.7-16.1%), positively influenced both beliefs about consequences regarding salbutamol use (intervention clinicians = 49%, control = 29%, difference = 20.3%, 95% CI = 13.2-27.4%) and nurses questioning non-evidence-based bronchiolitis management (chest X-ray: intervention = 71%, control = 51%, difference = 20.8%, 95% CI = 11.4-30.2%; glucocorticoids: intervention = 64%, control = 40%, difference = 21.9%, 95% CI = 10.4-33.5%) (social/professional role and identity). A 14% improvement in evidence-based bronchiolitis management favouring intervention hospitals was demonstrated in the cluster randomised controlled trial. CONCLUSION Targeted interventions positively changed factors influencing bronchiolitis management resulting in improved evidence-based bronchiolitis care. This study has important implications for improving bronchiolitis management and future development of interventions to de-implement low-value care.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Nursing, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Diana Zannino
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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16
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Parker G, Shahid N, Rappon T, Kastner M, Born K, Berta W. Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implement Sci 2022; 17:6. [PMID: 35057832 PMCID: PMC8772067 DOI: 10.1186/s13012-021-01177-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Nida Shahid
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Tim Rappon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Monika Kastner
- Centre for Research and Innovation, North York General Hospital, 4001, Leslie Street, Toronto, Ontario M2K 1E1 Canada
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
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17
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Haskell L, Tavender EJ, O'Brien S, Wilson CL, Babl FE, Borland ML, Schembri R, Orsini F, Cotterell E, Sheridan N, Oakley E, Dalziel SR. Process evaluation of a cluster randomised controlled trial to improve bronchiolitis management - a PREDICT mixed-methods study. BMC Health Serv Res 2021; 21:1282. [PMID: 34844605 PMCID: PMC8628472 DOI: 10.1186/s12913-021-07279-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for hospitalisation in infants. All international bronchiolitis guidelines recommend supportive care, yet considerable variation in practice continues with infants receiving non-evidence based therapies. We developed six targeted, theory-informed interventions; clinical leads, stakeholder meeting, train-the-trainer, education delivery, other educational materials, and audit and feedback. A cluster randomised controlled trial (cRCT) found the interventions to be effective in reducing use of five non-evidence based therapies in infants with bronchiolitis. This process evaluation paper aims to determine whether the interventions were implemented as planned (fidelity), explore end-users' perceptions of the interventions and evaluate cRCT outcome data with intervention fidelity data. METHODS A pre-specified mixed-methods process evaluation was conducted alongside the cRCT, guided by frameworks for process evaluation of cRCTs and complex interventions. Quantitative data on the fidelity, dose and reach of interventions were collected from the 13 intervention hospitals during the study and analysed using descriptive statistics. Qualitative data identifying perception and acceptability of interventions were collected from 42 intervention hospital clinical leads on study completion and analysed using thematic analysis. RESULTS The cRCT found targeted, theory-informed interventions improved bronchiolitis management by 14.1%. The process evaluation data found variability in how the intervention was delivered at the cluster and individual level. Total fidelity scores ranged from 55 to 98% across intervention hospitals (mean = 78%; SD = 13%). Fidelity scores were highest for use of clinical leads (mean = 98%; SD = 7%), and lowest for use of other educational materials (mean = 65%; SD = 19%) and audit and feedback (mean = 65%; SD = 20%). Clinical leads reflected positively about the interventions, with time constraints being the greatest barrier to their use. CONCLUSION Our targeted, theory-informed interventions were delivered with moderate fidelity, and were well received by clinical leads. Despite clinical leads experiencing challenges of time constraints, the level of fidelity had a positive effect on successfully de-implementing non-evidence-based care in infants with bronchiolitis. These findings will inform widespread rollout of our bronchiolitis interventions, and guide future practice change in acute care settings. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415 .
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag, Auckland, 92019, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia.,Curtin University, Perth, WA, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials, Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials, Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, NSW, Australia.,School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag, Auckland, 92019, New Zealand. .,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
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18
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Friedman JN, Davis T, Somaskanthan A, Ma A. Avoid doing chest x rays in infants with typical bronchiolitis. BMJ 2021; 375:e064132. [PMID: 34686495 DOI: 10.1136/bmj-2021-064132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jeremy N Friedman
- Paediatrics, Hospital for Sick Children, Toronto, Ontario M3B 3E8, Canada
| | - Tessa Davis
- Paediatric Emergency Department, Royal London Hospital, London, UK
| | | | - Amy Ma
- Family Advisory Forum, Montreal Children's Hospital, Montreal, Quebec, Canada
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19
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Hester G, Nickel AJ, Watson D, Bergmann KR. Factors Associated With Bronchiolitis Guideline Nonadherence at US Children's Hospitals. Hosp Pediatr 2021; 11:1102-1112. [PMID: 34493589 DOI: 10.1542/hpeds.2020-005785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children's hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20-3.60; admissions: aOR, 2.97; CI, 2.79-3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10-1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17-1.41) and bronchodilators (aOR, 1.39; CI, 1.31-1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.
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Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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20
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Haskell L, Tavender EJ, Wilson CL, O'Brien S, Babl FE, Borland ML, Cotterell E, Sheridan N, Oakley E, Dalziel SR. Development of targeted, theory-informed interventions to improve bronchiolitis management. BMC Health Serv Res 2021; 21:769. [PMID: 34344383 PMCID: PMC8335893 DOI: 10.1186/s12913-021-06724-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. METHODS A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. RESULTS Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. CONCLUSION A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Curtin University, Perth, Western Australia, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Austalia, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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21
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Haskell L, Tavender EJ, Wilson CL, O’Brien S, Babl FE, Borland ML, Cotterell E, Schembri R, Orsini F, Sheridan N, Johnson DW, Oakley E, Dalziel SR. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:797-806. [PMID: 33843971 PMCID: PMC8042564 DOI: 10.1001/jamapediatrics.2021.0295] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care. OBJECTIVE To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020. INTERVENTIONS Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback. MAIN OUTCOMES AND MEASURES The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions. RESULTS A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001). CONCLUSIONS AND RELEVANCE Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
| | - Emma J. Tavender
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Catherine L. Wilson
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Sharon O’Brien
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Curtin University, Bentley, Western Australia, Australia
| | - Franz E. Babl
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,Pediatric Emergency Medicine, University of Melbourne, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children’s Hospital, Western Australia, Australia,Faculty of Health and Medical Sciences (Pediatrics and Emergency Medicine), The University of Western Australia, Western Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, New South Wales, Australia,School of Rural Medicine, University of New England, New South Wales, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Center, Murdoch Children’s Research Institute, Victoria, Australia
| | - Nicolette Sheridan
- Center for Nursing and Health Research, Massey University, Auckland, Auckland, New Zealand
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ed Oakley
- Emergency Research, Murdoch Children’s Research Institute, Victoria, Australia,The Royal Children’s Hospital Melbourne, Victoria, Australia,University of Melbourne, Victoria, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand,Departments of Surgery and Pediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
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22
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O’Rourke R, Lima ML, Jetten J. Healthcare professionals and medical cannabis: a scoping review informed by the theoretical domains framework. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01624-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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23
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Klassen TP, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van de Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care. Emerg Med Australas 2021; 33:900-910. [PMID: 34218513 DOI: 10.1111/1742-6723.13801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks. METHODS PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic. CONCLUSIONS Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.
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Affiliation(s)
- Terry P Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Pediatric Emergency Research Canada (PERC)
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT)
| | - Franz E Babl
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain.,Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG)
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy.,Research in European Pediatric Emergency Medicine (REPEM)
| | - James Chamberlain
- Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Pediatric Emergency Care Applied Research Network (PECARN)
| | - Todd P Chang
- Pediatric Emergency Care Applied Research Network (PECARN).,Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California, USA.,Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
| | - Stephen B Freedman
- Pediatric Emergency Research Canada (PERC).,Departments of Pediatrics and Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Guillermo Kohn Loncarica
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI)
| | - Santiago Mintegi
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG).,Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Department of Paediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Lise E Nigrovic
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rianne Oostenbrink
- Research in European Pediatric Emergency Medicine (REPEM).,General Pediatrics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Amy C Plint
- Pediatric Emergency Research Canada (PERC).,Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pedro Rino
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Damian Roland
- Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI).,Children's Emergency Department, University of Leicester, Leicestershire, UK
| | - Greg Van de Mosselaer
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Translating Emergency Knowledge for Kids, Winnipeg, Manitoba, Canada
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network (PECARN).,Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
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24
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Klassen T, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn-Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van De Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care. Pediatr Emerg Care 2021; 37:389-396. [PMID: 34091572 PMCID: PMC8244934 DOI: 10.1097/pec.0000000000002466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks. METHODS The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings. CONCLUSIONS The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.
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Affiliation(s)
- Terry Klassen
- From the Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba
- The Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Pediatric Emergency Research Canada
| | - Stuart R. Dalziel
- Departments of Surgery
- Paediatrics: Child and Youth Health, University of Auckland
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative
| | - Franz E. Babl
- Paediatric Research in Emergency Departments International Collaborative
- Departments of Paediatrics
- Critical Care, University of Melbourne, Australia
- Emergency Research, Murdoch Children's Research Institute, Melbourne
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group
| | - Silvia Bressan
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Research in European Pediatric Emergency Medicine
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Pediatric Emergency Care Applied Research Network
| | - Todd P. Chang
- Pediatric Emergency Care Applied Research Network
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Calgary, AB, Canada
- Division of Pediatric Emergency Medicine, Pediatric Emergency Care Applied Research Network (PECARN), Los Angeles, CA
| | - Stephen B. Freedman
- Pediatric Emergency Research Canada
- Section of Pediatric Emergency Medicine, Department of Pediatrics
- Section of Gastroenterology, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary
- Division of Pediatric Emergency Medicine, Pediatric Emergency Research Canada (PERC), Calgary, AB, Canada
| | - Guillermo Kohn-Loncarica
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Mark D. Lyttle
- Emergency Department, Bristol Royal Hospital for Children
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Research in the United Kingdom and Ireland, Bristol, United Kingdom
| | - Santiago Mintegi
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
| | - Rakesh D. Mistry
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Denver, CO
| | - Lise E. Nigrovic
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Emergency Medicine, Boston Children's Hospital
- Department of Emergency Medicine, Harvard Medical School
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Boston, MA
| | - Rianne Oostenbrink
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Department of General Pediatrics, ErasmusMC–Sophia
- Division of Pediatric Emergency Medicine, Research in European Pediatric Emergency Medicine, Rotterdam, the Netherlands
| | - Amy C. Plint
- Pediatric Emergency Research Canada
- Children's Hospital of Eastern Ontario
- Pediatrics
- Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pedro Rino
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Damian Roland
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Medicine Leicester Academic Group
- Children's Emergency Department, Leicester Royal Infirmary
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, United Kingdom
| | - Gregory Van De Mosselaer
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Translating Emergency Knowledge for Kids
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network
- Departments of Emergency Medicine
- Pediatrics, University of California Davis School of Medicine, Sacramento, CA
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Kilpatrick M, Hutchinson A, Manias E, Bouchoucha SL. Paediatric nurses', children's and parents' adherence to infection prevention and control and knowledge of antimicrobial stewardship: A systematic review. Am J Infect Control 2021; 49:622-639. [PMID: 33285224 DOI: 10.1016/j.ajic.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Infection prevention and control precautions help to decrease microbial transmission, and through the appropriate use of antibiotics, Antimicrobial Stewardship programs aim to decrease the prevalence and emergence of Antimicrobial Resistance. METHODS A systematic review was undertaken to critically appraise and synthesise evidence for nurses', children's and parents' knowledge and understanding of antimicrobial stewardship, and of infection prevention and control in acute paediatric care settings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guided the review. Studies were included if they examined the factors that contributed to nurses' adherence to, or consumers' practice in relation to, antimicrobial stewardship and infection prevention and control. RESULTS Of the 16,957 papers identified, 50 studies conducted in acute paediatric settings met the eligibility criteria, and were included. Most studies were of low methodological quality. Fourteen studies evaluated nurses' knowledge and self-reported adherence to Infection Prevention and Control principles and identified consistent practice gaps by nurses. Six studies evaluating the effectiveness of education programs reported modest improvements in nurses' knowledge and adherence to infection prevention and control. There were 15 studies, that investigated consumers' involvement in infection prevention and control that identified the following themes: Consumer knowledge and attitudes to infection prevention and control and transmission-based precautions, and parents' willingness to take an active role in infection prevention. Six studies focused on paediatric nurses' role in antimicrobial stewardship, exploring the following themes: (1) nurses' understanding and beliefs of antimicrobial stewardship roles, and (2) barriers to nurses taking a greater role in antimicrobial stewardship. Nine studies explored the role of consumers in antimicrobial stewardship and identified consumers' misconceptions about the benefits and downplayed concerns regarding antibiotic use. DISCUSSION Although consumers articulated a willingness to be actively involved in infection prevention, observed practice remained lower than that required to consistently prevent infection transmission. CONCLUSION These findings highlight a critically important gap in current practice. In relation to optimal use of antimicrobials, although paediatric nurses were involved in supporting antimicrobial stewardship processes and educating consumers, they identified limited antimicrobial stewardship knowledge. Consumers appeared to lack understanding about the benefits of antibiotics and negated concerns regarding antibiotic use.
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Affiliation(s)
- Mataya Kilpatrick
- Deakin University Geelong, Australia, School of Nursing and Midwifery, Centre for Quality and Patient Safety in Institute for Health Transformation, Burwood, Australia
| | - Ana Hutchinson
- Deakin University Geelong, Australia, School of Nursing and Midwifery, Centre for Quality and Patient Safety in Institute for Health Transformation, Burwood, Australia
| | - Elizabeth Manias
- Deakin University Geelong, Australia, School of Nursing and Midwifery, Centre for Quality and Patient Safety in Institute for Health Transformation, Burwood, Australia
| | - Stéphane L Bouchoucha
- Deakin University Geelong, Australia, School of Nursing and Midwifery, Centre for Quality and Patient Safety in Institute for Health Transformation, Burwood, Australia.
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