A pragmatic cluster randomised trial evaluating three implementation interventions

Background Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting. Methods A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients' experiences, and stakeholders' experiences of implementation, including influences. ANOVA was used to test differences over time and interventions. Results Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility. Conclusions This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions' impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance. Trial registration ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE

Is it possible to incorporate quality into hospital pricing systems?

Australia has recently implemented an activity - based funding system for public hospitals. Policymakers and providers are keen to ensure that the price paid for health care services stimulates improvements in quality and safety , but some remain scept ical that this can be achieved through pricing mechanisms. There are four main ways of linking quality and safety to hospital pricing in the context of activity based funding: Best-practice pricing This involves making evidenced - based decisions on what constitutes ‘best-practice’ for the treatment of a particular condition, then paying health services a set price when they provide best-practice care. Normative pricing This involves using price to influence the delivery of care (for example, providing incentives to deliver more care in the home for certain conditions or to provide day surgery options where appropriate). Structural models of pricing quality This involves linking funding to meeting accreditation standards or participating in benchmarking activities or clinical quality registries. Payment for Performance (P4P) or quality pricing This involves using financial incentives and/or disincentives to encourage providers to behave in certain ways that will improve quality and safety. This paper briefly examines the strength of the evidence for each of these pricing models. It considers both peer-reviewed research as well as non peer-reviewed material, such as program evaluations and government reports

Iowa Community Empowerment Newsletter, December 2002, Vol. 3, no. 6

Monthly newsletter for the Iowa Department of Public Healt

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

A Reinforcement Learning Approach to Weaning of Mechanical Ventilation in Intensive Care Units

The management of invasive mechanical ventilation, and the regulation of sedation and analgesia during ventilation, constitutes a major part of the care of patients admitted to intensive care units. Both prolonged dependence on mechanical ventilation and premature extubation are associated with increased risk of complications and higher hospital costs, but clinical opinion on the best protocol for weaning patients off of a ventilator varies. This work aims to develop a decision support tool that uses available patient information to predict time-to-extubation readiness and to recommend a personalized regime of sedation dosage and ventilator support. To this end, we use off-policy reinforcement learning algorithms to determine the best action at a given patient state from sub-optimal historical ICU data. We compare treatment policies from fitted Q-iteration with extremely randomized trees and with feedforward neural networks, and demonstrate that the policies learnt show promise in recommending weaning protocols with improved outcomes, in terms of minimizing rates of reintubation and regulating physiological stability

Innovative Approaches to Emergency Medical Services Fellowship Challenges

Introduction: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum.Methods: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows’ rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician.Results: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system.Conclusion: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges

Lifting the Burden of Addiction: Philanthropic Opportunities to Address Substance Use Disorders in the United States

Substance use disorders (SUDs), also known as substance abuse or addiction, affect an estimated 20 million or more adolescents and adults in the U.S. This guidance provides philanthropic funders with the tools & information to reduce immediate harm from substance use disorders and reduce the burden of the disorder over the long term. This includes reducing the damage the disorder causes to people with SUDs and their loved ones, reducing the overall incidence of SUDs, and reducing SUD-related costs to society. We present four strategies for philanthropic funders who want to help:- Save lives and reduce SUD-related illness and homelessness- Improve access to evidence-based treatment- Improve SUD care by changing systems and policies- Fund innovation to improve prevention and treatmen

Flexible PCL tube scaffolds by winding of micro-extruded filaments

An important requirement for tissue engineering scaffolds is matching of the functional me-chanical properties to their natural tissue counterpart. Specifically for arteries this comprises the elastic re-sponse of the vessel wall to blood pressure. Human aorta has a low elastic modulus when compared to some FDA-approved synthetic polymer materials frequently used in tissue engineering. The current research en-deavours to expand the existing production technology of 3D plotting to winding of micro-extruded filaments in order to obtain flexible polymer tubes with continuous fibre. Tube scaffolds are manufactured by conven-tional 3D plotting and by winding. Their structure and quasi-static mechanical properties are evaluated and compared to human aorta. Winded tubes are found to be far more suitable for application as a blood vessel scaffold than their 3D plotted counterparts

THE IMPLICATURE AND VIOLATION OF MAXIMS IN INDONESIAN ADVERTISEMENTS

We all know that advertising is a business in which language is used to persuade people to do things (e.g., buy some product) and / or believe things (believing that the value of the product is trustworthy or a good one). The phenomenon, however, is that we tend to doubtthe truth conditions of the advertisements. In other words, we do not take those ads seriously. We are not very affected emotionally yet we are just amused and regard them as entertaining fallacies (e.g. the “AXE” male perfume). Some reasons might verify this fact. However, this paper is just concerned with the language phenomenon existing in theadvertisement world. A common shared perspective on the advertisement language within Indonesian ads is, among others, bombastic, hyperbolic, and many times, irrational. Not the least, most of the ads have a similar tendency to “violate” the language as long as theproduct sells. Apparently, Indonesian ads are apt to employ indirect language(‘implicature’) in their emulating their own product and devaluing their competitor’s product (e.g. the then Yahama’s “Yang Lain Makin Ketinggalan”). Upon these intriguing facts, this paper attempts to highlight general features of Indonesian advertisements in termsof (1) the violation of Grice’s conversational maxims (rules and norms) and (2) implicature(extended meaning). Alternating a more ‘acceptable’ model of ads could be a by-product ofthis paper

Mapping Health Care Innovation: Tracing Walls & Ceilings

Health care is in need of innovation on many strands. Patient-centered care appears to be the key to the realization of the main objectives: service quality, cost reduction, access, patient satisfaction and the quality of working life. Innovation, and more precisely, the diffusion and implementation of new methods, new techniques and new processes and systems appears to be a difficult task. Consequently, there is a strong need for knowledge about innovation processes in health care and the drivers and barriers affecting these efforts. This paper presents a framework for mapping innovation processes in health care services. The framework consists of two axes: (1) the horizontal axis of the health care process and the inter-functional walls which can complicate innovation efforts, and (2) the vertical axis of the echelons of power, which often create ceilings too impermeable to permit effective learning and decision making. The study is based on the experiences gathered in Publin, a running research network supported by the Fifth Framework Program and Innoflex, which ended in 2003.economics of technology ;