Uptake of Best-Practice Recommendations for Management of Acutely Ill Children Admitted in Kenyatta National Hospital: A Longituinal Study Employing Participatory Research in a Complex Environment

The need for improving practice in low-income settings has been demonstrated in recent research assessing the quality of hospital care. Consequently, the Ministry of Health developed clinical practice guidelines and an evidenced-based programme for their dissemination. This thesis explored what factors influence the uptake of the best-practice recommendations in a university teaching hospital. This thesis used a mixed methods research approach that utilized a before and after design and participatory action research. This approach recognizes that health recommendations are compiled for universal use, but that their successful implementation requires particular attention to the individual and complex socio-political contexts of each setting, both at the micro and -macro level, which in this case was the Kenyatta National Hospital (KNH). This thesis is supported by eighteen months of participant observation, based on ethnographic research methodology and action research. Patients' care was largely inconsistent with best-practice recommendations, with nine of the 17 key indicators having performance of below 10% in the pre-intervention period. The intervention had an absolute effect size of over 20% in eight of the 17 key indicators; three of which had an effect size of over 50%. The indicators that required collective efficacy achieved performance of less than 10% in the post-intervention period. The activities during the action research component failed to predict the trend in practitioners' performance, illustrating the difficulty of gaining a holistic understanding of the quantitative results using component parts of the qualitative results as the lens. The notion of professionalism provided an overarching understanding of the implementation process. There were clear gaps between the stated values espoused in the ideal of professionalism and the observed actions of professionals in KNH. Gaps spanned knowledge management, expertise and skills, teamwork, conscientiousness and patient centeredness. I attributed the gaps in professionalism to complexity of professional development

Estimating Defensive Cyber Operator Decision Confidence

As technology continues to advance the domain of cyber defense, signature and heuristic detection mechanisms continue to require human operators to make judgements about the correctness of machine decisions. Human cyber defense operators rely on their experience, expertise, and understanding of network security, when conducting cyber-based investigations, in order to detect and respond to cyber alerts. Ever growing quantities of cyber alerts and network traffic, coupled with systemic manpower issues, mean no one has the time to review or change decisions made by operators. Since these cyber alert decisions ultimately do not get reviewed again, an inaccurate decision could cause grave damage to the network and host systems. The Cyber Intruder Alert Testbed (CIAT), a synthetic task environment (STE), was expanded to include investigative pattern of behavior monitoring and confidence reporting capabilities. By analyzing the behavior and confidence of participants while they conducted cyber-based investigations, this research was able to identify a mapping between investigative patterns of behavior and decision confidence. The total time spent on a decision, the time spent using different investigative tools, and total number of tool transitions, were all factors which influenced the reported confidence of participants when conducting cyber-based investigations

Optimising feedback for early career professionals: a scoping review and new framework

Context Meta‐analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. Methods We undertook a scoping literature review, using search terms such as ‘feedback’ and ‘effectiveness’ in MEDLINE, MEDLINE‐In‐Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. Results A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. Conclusions We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences

Steps to Reducing Heart Failure Hospital Readmissions Through Improvement in Outpatient Care

The outpatient care of the heart failure (HF) patient is fragmented due to the lack of evidence-based practice guidelines use. The primary goal of this project was to improve the care of the HF patient in the outpatient arena through use of clinical pathways using the logic model as the project framework. The intervention was carried out over a 4-week period on a convenience, random sample of patients (n = 80) attending a cardiology practice. The patients were recruited from 2 physicians\u27 patient populations and were selected based on an adult diagnosis of HF, reduced ejection fraction of \u3c40% at some point in time, and the New York Heart Association (NYHA) functional class II-V. Comparisons were made in the documentation of care between patients on or off the pathway. The intervention included documentation of patient education, care follow-up, medications, NYHA functional class, and symptom exacerbation, documented in the electronic medical record. The quality of care data were evaluated based on 3 of the Joint Commission core measures for outpatient care of the HF patient. Additional data were collected regarding use of the clinical pathway based on provider and week of implementation. Data were analyzed via a Chi-square test of independence comparing pathway use by provider and use of pathway as study progressed. The comparative results show statistically significant differences in use of the pathway by provider and a statistically significant increase in use during the project . The quality of care results varied in statistical significance. The pathway utilization increased over time and provided a method for standardizing documentation of care for the HF patient in this outpatient clinic, a benefit for HF patients and providers in this cardiology practice and beyond

Evaluating Evaluations of Clinical Decision Support Systems: Case Studies From NHS Clinical Settings

The NHS is under increasing pressure to cut costs while delivering high quality care. At the same time, the demand for healthcare services has grown, driven in part by the increasing number of older people in the population. NHS Trusts are adopting clinical decision support systems (CDSSs) to help decision making at the point of care. CDSSs are said to bring benefits such as improvements in guideline adherence, clinical processes and user performance but evidence of these benefits is not always available and their effectiveness in terms of improving patient outcomes is often open to question. This thesis presents research that was carried out in a large teaching NHS Trust looking at the evaluations of three CDSSs. Semi structured interviews were carried out with key informants who were involved in their adoption, use and evaluations. Documentary analysis and observations were also used to augment the interviews. Most evaluations were carried out informally by the developers and were primarily driven by external regulatory pressures rather than patient outcomes and organisational needs. Evaluation documentation was inadequate or missing, thus making it difficult to systematically assess these evaluations. This thesis contends that evaluations are important to provide decision makers in NHS Trusts with adequate information to make decisions about CDSSs and computerised healthcare information technologies in general. NHS Trusts need to build organisational capacity and readiness to enable them to effectively carry out evaluations that will provide meaningful information to gain better understanding of CDSSs and to inform their successful adoption, implementation, usage and to justify the resource allocation. This research shows that CDSS evaluations investigated took a predominantly narrow view. It thus provides evidence for the need for a more systemic approach to evaluation

Structural and Care Process Improvement of Ward-based Postoperative Care to Optimise Surgical Outcomes

Much of the variation seen in surgical outcomes can be explained by differences in the quality of management of post-operative complications and ward-based care. The surgical ward round (WR) is critical to determining post-operative care and serves as the primary point of interaction between clinician and patient. Despite this, it is an area not subject to training or assessment at present. This thesis demonstrates the high degree of variability which exists in the conduct of WRs. It establishes the link between suboptimal patient assessment and increased risk of preventable post-operative complications. These place patients not only at risk of short-term deterioration, but result in reduced long-term survival as well. In order to quantify WR quality, a novel assessment tool has been developed and validated within a simulated environment. Ward simulation is a nascent branch of simulation which has been only preliminarily explored to date. A simulation environment was developed to take advantage of the known benefits of simulation such as controllability, reproducibility, and recordability, whilst maintaining a high level of fidelity and realism. An evidence-based curriculum for surgical WR training was designed and implemented in a simulation-based course. By focusing on structured generic processes of patient assessment and management, this resulted in significant improvement of trainee performance in routine WRs. To ensure standardised and optimum management of specific conditions, checklists have proven themselves to be of great value in a number of surgical and medical disciplines. Surgical complications are common, yet their management often suboptimal. As part of this thesis, evidence-based protocols for the management of the six most common complications were designed and validated. The implementation of these in a simulation-based randomised, controlled trial has resulted in greatly increased adherence to evidence-based standards of care, as well as improved communication and clinician performance. This thesis explores the variance currently present in surgical ward rounds, and the potentially grave consequences of this for patient outcomes. To date, WRs have been one of the last areas of surgical care still dependent on the Halstedian principle of experiential learning alone. The tools have now been developed with which to assess, improve, and standardise critical structures and care processes in the assessment and management of the post-operative surgical patient. Future implementation of these and integration into surgical curricula will benefit clinician training, patient care, and surgical outcomes alike.Open Acces

Reducing Catheter-Associated Urinary Tract Infection Project

Practice Problem: Catheter-associated urinary tract infections (CAUTIs) are prevalent and responsible for an estimated 13,000 deaths annually in the United States. Reported cases of CAUTIs remain disproportionately high at a rehabilitation center located in South Texas. PICOT: This evidence-based project answered the following question: In rehabilitation patients, what is the effect of a nurse-driven protocol (NDP) CAUTI bundle on the number of indwelling urinary catheter-related infections, compared to the current practice, over a 12-week time period? Evidence: Twenty high-quality studies that met the inclusion and exclusion criteria recommended using an NDP CAUTI bundle, education, and champions to round the unit to decrease the number of catheter-associated urinary tract infections. Intervention: The evidence-based intervention utilized the implementation of an NDP CAUTI bundle. The intervention bundle included catheter indication, hand hygiene, an insertion technique, maintenance, ongoing assessment to evaluate catheter need, and documentation. Outcome: The evaluation of the outcome measures demonstrated that the CAUTI rate decreased from six incidences in 2019 to two from January to May 2020. There were zero incidences during the project implementation from June to August 2020, and the number of catheter days decreased from 59% at baseline to 41% post-intervention. Conclusion: The implementation of a nurse-driven protocol CAUTI bundle, education, and champions in the unit were successful interventions that decreased the catheter-associated urinary tract infection rates in the rehabilitation center. Keywords: catheter-associated urinary tract infections, nurse-driven protocol CAUTI bundle, quality improvemen

Evaluation of impact of antimicrobial stewardship in limiting the spread of antimicrobial resistance in Gauteng Province

The threat of antimicrobial resistance particularly in the intensive care unit has become a global issue. This study aimed to evaluate the effectiveness of antimicrobial stewardship in limiting the spread of antimicrobial resistance in the hospital’s ICU. The study further determined the deficiencies of the ASP and recommended strategies to remedy the identified deficiencies. A quasi-experimental descriptive quantitative design was used in this study. The study was conducted at the intensive care unit of an academic hospital. A structured questionnaire was used to extract information from patients’ medical records. This evaluation showed that the antimicrobial stewardship program had a sufficient impact on the appropriate use of antimicrobials in the hospital’s ICU. While there were a small (19.05 %) number of patients inappropriately prescribed antimicrobials, a moderate (35.59%) number of patients developed hospital acquired infections during the study period. In addition, the results revealed a lack of the facility’s leadership commitment to antimicrobial stewardship, which is crucial for ensuring the availability of human, financial and information technology resources Through the evaluation of the program the deficiency in the program’s performance can be identified and optimised. For the studied facility, the performance of the program could be improved by gaining the support of the facility leadership. The present study endorses the evaluation of health promotion initiatives to improve patients’ safety and outcome in healthcare institutions. KeywordsHealth StudiesD. Litt. et Phil. (Health Studies