CogChamps - a model of implementing evidence-based care in hospitals: study protocol

Mapping implementation strategies of evidence-based interventions for three preselected phenomena in people with dementia-a scoping review

BACKGROUND

Caring for people with dementia is complex, and there are various evidence-based interventions. However, a gap exists between the available interventions and how to implement them. The objectives of our review are to identify implementation strategies, implementation outcomes, and influencing factors for the implementation of evidence-based interventions that focus on three preselected phenomena in people with dementia: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs.

METHODS

We conducted a scoping review according to the description of the Joanna Briggs Institute. We searched MEDLINE, CINAHL, and PsycINFO. For the data analysis, we conducted deductive content analysis. For this analysis, we used the Expert Recommendations for Implementation Change (ERIC), implementation outcomes according to Proctor and colleagues, and the Consolidated Framework for Implementation Research (CFIR).

RESULTS

We identified 362 (A), 544 (B), and 714 records (C) on the three phenomena and included 7 (A), 3 (B), and 3 (C) studies. Among the studies, nine reported on the implementation strategies they used. Clusters with the most reported strategies were adapt and tailor to context and train and educate stakeholders. We identified one study that tested the effectiveness of the applied implementation strategy, while ten studies reported implementation outcomes (mostly fidelity). Regarding factors that influence implementation, all identified studies reported between 1 and 19 factors. The most reported factors were available resources and the adaptability of the intervention. To address dementia-specific influencing factors, we enhanced the CFIR construct of patient needs and resources to include family needs and resources.

CONCLUSIONS

We found a high degree of homogeneity across the different dementia phenomena, the evidence-based interventions, and the care settings in terms of the implementation strategies used, implementation outcomes measured, and influencing factors identified. However, it remains unclear to what extent implementation strategies themselves are evidence-based and which intervention strategy can be used by practitioners when either the implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown. Future research needs to focus on investigating the effectiveness of implementation strategies for evidence-based interventions for dementia care.

TRIAL REGISTRATION

The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021).

Knowledge of autism gained by learning from people through a local UK Autism Champion Network: A health and social care professional perspective

LAY ABSTRACT

The Autism Act 10 Years On found few autistic adults thought health and social care professionals had a good understanding of autism. Autism training has been made law in the United Kingdom for health and social care staff to tackle health inequality. The county wide Autism Champion Network evaluated here is an equal partnership of interested staff across sectors (Autism Champions) and autistic experts by virtue of lived experience (Autism Advisory Panel). With knowledge flowing both ways, the Autism Champions take learning back to teams to support continuous development of services to meet autistic need. Seven health and social sector professionals from the Network participated in semi-structured interviews on sharing knowledge of autism gained with their teams. All participants provide care and support for autistic people, some working in specialist positions. Results showed that developing new relationships with people outside their own team to signpost to, answer questions and share resources, and informal learning from autistic people, was more valued and used in practice than information gained from presentations. These results have implications in developing learning for those who need above a basic knowledge of autism and may be useful for others considering setting up an Autism Champion Network.

Massachusetts Intensive Care Unit Nurses From Multiple Hospitals Develop a Collaborative to Improve Delirium Assessment Accuracy

BACKGROUND AND RELEVANCE

Early recognition of delirium mobilizes nurses to intervene in a timely manner to minimize cognitive, physical, and mental health burdens. The life-altering challenges of unrecognized delirium in intensive care unit (ICU) patients motivated a group of Massachusetts ICU nurse leaders to form a collaborative and improve delirium screening accuracy in 4 area hospitals.

LOCAL PROBLEM

Baseline audits confirmed a lack of delirium screening accuracy across multiple institutions. The purpose of this article is to describe how our collaborative was developed and to outline our delirium accuracy assessment program.

METHODS

In March of 2015, 2 graduates from the Clinical Scene Investigator Academy contacted members within the Boston cohort to form a regional collaborative to improve patient outcomes. The purpose of our project was to improve our delirium assessment accuracy to greater than 80% in patients across our ICUs. Using a successful project, we scaled this work based on the needs of each institution. A preaudit-postaudit design was used to evaluate the effectiveness of our programs.

RESULTS

Data showed an improved overall accuracy assessment of 88.3% (P < .01), whereas the patients with an altered Richmond Agitation Sedation Scale markedly improved to 87.7% (P < .01).

CONCLUSIONS

Every ICU in the United States is working on improving reportable quality metrics, but all too often, this work is being done in silos. When critical care nurses have the knowledge, skills, and time to work together, they can begin to transform health care.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

BACKGROUND

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

AIM

This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

METHODS

This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

RESULTS

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

LINKING EVIDENCE TO ACTION

Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program

OBJECTIVE

To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium.

METHODS

A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method.

RESULTS

Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99).

CONCLUSIONS

Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Aged care clinical mentoring model of change in nursing homes in China: study protocol for a cluster randomized controlled trial

Background

Residents living in nursing homes usually have complex healthcare needs and require a comprehensive care approach to identifying and meeting their care needs. Suboptimal quality of care is reported in nursing homes and is associated with the poor health and well-being of the residents, the burden on acute care hospitals and the high costs of healthcare for the government.

The aim of this study is to test the hypothesis that an Aged Care Clinical Mentoring Model will create and sustain evidence-based quality improvement in priority areas and will be cost-effective in nursing homes in Hunan Province, China.

Methods

A cluster randomized controlled trial will be applied to the study. Fourteen nursing homes will be randomly allocated to either the intervention group (n = 7) or the control group (n = 7). Forty staff will be recruited from each nursing home and the estimated sample size will be 280 staff in each group. The intervention includes a structured, evidence-based quality improvement education program for staff to facilitate knowledge translation in evidence-based quality improvement targeting urinary incontinence, pressure injury and falls prevention. The primary outcomes are nursing homes’ capacity to create and sustain quality improvement, staff perceptions of person-centered care, self-reported quality of care by residents and selected quality indicators at 12 months follow-up adjusted for baseline value. Secondary outcomes are residents’ quality of life, residents’ unplanned admissions to acute care hospitals, quality of care reported by staff, staff job satisfaction and staff intention to leave adjusted for baseline value. A mixed linear regression model will be adopted to compare the significant differences between groups over a 12-month period.

Discussion

Although the Aged Care Clinical Mentoring Model has been tested as an effective model to bring positive changes in nursing homes in a high-income country, factors affecting the adaptation of the model in nursing homes in low- and middle-income countries are unknown. The carefully planned intervention protocol enables the project team to consider enablers and barriers when adapting the Model. Therefore, strategies and resources will be in place to manage challenges while demonstrating best practice in this study.

Trial registration

Prospectively registered via Chinese Clinical Trial Registry (ChiCTR), ChiCTR-IOC-17013109, Registered on 25 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3596-6) contains supplementary material, which is available to authorized users.

CogChamps: impact of a project to educate nurses about delirium and improve the quality of care for hospitalized patients with cognitive impairment

BACKGROUND

Achieving sustainable practice changes to ensure best-practice nursing care in acute hospital environments can be challenging and is not well understood. A multi-faceted practice change intervention was implemented in a large Australian hospital to enhance the capacity of the nursing workforce to provide quality care for older patients with cognitive impairment (CI).

METHODS

Thirty-four experienced Registered Nurses (RNs) became Cognition Champions (CogChamps), and led practice-change initiatives to improve nursing care for older patients (≥65 years) on six wards in one hospital. The CogChamps received comprehensive education about dementia and the identification, prevention, and management of delirium. Over five months, they were supported to develop and implement ward-specific Action Plans designed to change care practices. Nurse-patient interactions were observed and patient charts were audited prior to the implementation of the plans and regularly throughout, using a purpose built Audit/ Observational tool. Data were also collected at a comparable hospital where there were no CogChamps. Data were analyzed for evidence of practice change.

RESULTS

Observational and audit data were collected for 181 patients (average age = 82.5 years) across the two hospitals. All patients had CI and both cohorts had similar behavioral characteristics requiring a high level of care assistance [e.g. 38% displayed evidence of confusion/disorientation and a majority experienced meal-time difficulty (62-70%)]. While nursing practices were generally the same at both hospitals, some differences were evident (e.g. analgesia use was higher at the control hospital). Following implementation of Action Plans, significant increases in nurses' assessments of patients' cognitive functioning (35 to 69%), and administration of analgesia (27 to 48%) were observed at the intervention hospital, although only the improvement in cognitive assessments was maintained at three months follow-up. No other changes in nursing processes were evident.

CONCLUSION

The CogChamps project demonstrates how RN champions were empowered to educate their colleagues about dementia and delirium resulting in a sustained increase in cognitive assessments by ward nurses. Practice improvements were mostly associated with clearly defined Action Plan tasks and goals and where responsibility for task completion was clearly assigned. These elements appear to be important when implementing practice changes.

TRIAL REGISTRATION

Australian Clinical Trials Registration Number: ACTRN 12617000563369 . Retrospectively registered.

Turning education into action: Impact of a collective social education approach to improve nurses' ability to recognize and accurately assess delirium in hospitalized older patients

BACKGROUND

Although cognitive impairment including dementia and delirium is common in older hospital patients, it is not well recognized or managed by hospital staff, potentially resulting in adverse events. This paper describes, and reports on the impact of a collective social education approach to improving both nurses' knowledge of, and screening for delirium.

METHODS

Thirty-four experienced nurses from six hospital wards, became Cognition Champions (CogChamps) to lead their wards in a collective social education process about cognitive impairment and the assessment of delirium. At the outset, the CogChamps were provided with comprehensive education about dementia and delirium from a multidisciplinary team of clinicians. Their knowledge was assessed to ascertain they had the requisite understanding to engage in education as a collective social process, namely, with each other and their local teams. Following this, they developed ward specific Action Plans in collaboration with their teams aimed at educating and evaluating ward nurses' ability to accurately assess and care for patients for delirium. The plans were implemented over five months. The broader nursing teams' knowledge was assessed, together with their ability to accurately assess patients for delirium.

RESULTS

Each ward implemented their Action Plan to varying degrees and key achievements included the education of a majority of ward nurses about delirium and the certification of the majority as competent to assess patients for delirium using the Confusion Assessment Method. Two wards collected pre-and post-audit data that demonstrated a substantial improvement in delirium screening rates.

CONCLUSION

The education process led by CogChamps and supported by educators and clinical experts provides an example of successfully educating nurses about delirium and improving screening rates of patients for delirium.

TRIAL REGISTRATION

ACTRN 12617000563369.