Implementation strategy fidelity evaluation for a multidisciplinary Chest Injury Protocol (ChIP)

Assessment of Barriers, Supports, and Context to Implement Best Practice Pain Management in the Emergency Department: The IMPAINED Study

AIM

To assess the emergency department practice context and identify strategies to improve outcomes of patients with acute pain.

BACKGROUND

Effective treatment of acute pain in the emergency department depends upon clinicians adopting pain interventions into practice. However, it is well-recognized that acute pain is often undertreated. The local practice context strongly influences clinicians' adoption of interventions into their clinical practice. An assessment of this practice context can inform implementation interventions and strategies to improve outcomes for patients with acute pain.

METHODS

Chart audit, staff survey, and staff working groups were conducted from June 2020 to May 2021 Data were analyzed and synthesized across sources informed by assessment elements of the Ottawa model of research use (OMRU) implementation model and expert recommendations for implementing change strategies.

RESULTS

The OMRU facilitated contextual assessment of pain treatment practice in the emergency department and the development of implementation strategies. Adoption of evidence-based pain interventions was low in the sample studied. Workflow and workload were the primary barriers to evidence-based pain practices by potential adopters, while positive beliefs and high awareness of evidence-based pain interventions were supportive factors. Implementation strategies were informed by assessment findings and mapped to the Ottawa model and expert recommendations for implementing change elements.

CONCLUSION

The adoption of evidence into practice in the emergency department relies upon a comprehensive assessment of the local context. The use of the OMRU assessment process resulted in meaningful engagement with staff and a deeper understanding of local pain management practices. Clinicians view evidence-based pain management as important, however, there are competing priorities within the emergency department, such as patient flow and triage. This study provides an exemplar of utilizing an implementation framework to identify pain practices within the emergency department.

CLINICAL IMPLICATIONS

Achieving impactful change in clinical practice to improve patient outcomes should start with the application of implementation methods that enable comprehensive analysis of the local practice context. The assessment should begin with collaboration with local clinicians that persist throughout the life of the study to ensure change is sustainable.

Fidelity to the ACT SMART Toolkit: an instrumental case study of implementation strategy fidelity

BACKGROUND

Evidence-based practices (EBPs) are shown to improve a variety of outcomes for autistic children. However, EBPs often are mis-implemented or not implemented in community-based settings where many autistic children receive usual care services. A blended implementation process and capacity-building implementation strategy, developed to facilitate the adoption and implementation of EBPs for autism spectrum disorder (ASD) in community-based settings, is the Autism Community Toolkit: Systems to Measure and Adopt Research-based Treatments (ACT SMART Toolkit). Based on an adapted Exploration, Adoption decision, Preparation, Implementation, Sustainment (EPIS) Framework, the multi-phased ACT SMART Toolkit is comprised of (a) implementation facilitation, (b) agency-based implementation teams, and (c) a web-based interface. In this instrumental case study, we developed and utilized a method to evaluate fidelity to the ACT SMART Toolkit. This study responds to the need for implementation strategy fidelity evaluation methods and may provide evidence supporting the use of the ACT SMART Toolkit.

METHODS

We used an instrumental case study approach to assess fidelity to the ACT SMART Toolkit during its pilot study with six ASD community agencies located in southern California. We assessed adherence, dose, and implementation team responsiveness for each phase and activity of the toolkit at both an aggregate and individual agency level.

RESULTS

Overall, we found that adherence, dose, and implementation team responsiveness to the ACT SMART Toolkit were high, with some variability by EPIS phase and specific activity as well as by ASD community agency. At the aggregate level, adherence and dose were rated notably lowest during the preparation phase of the toolkit, which is a more activity-intensive phase of the toolkit.

CONCLUSIONS

This evaluation of fidelity to the ACT SMART Toolkit, utilizing an instrumental case study design, demonstrated the potential for the strategy to be used with fidelity in ASD community-based agencies. Findings related to the variability of implementation strategy fidelity in the present study may also inform future adaptations to the toolkit and point to broader trends of how implementation strategy fidelity may vary by content and context.

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation

Background

Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel.

Methods

This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality.

Results

There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period.

Conclusion

The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement.

Trial registration

ANZCTR: ACTRN12618001548224, approved 17/09/2018