Identification of factors that support successful implementation of care bundles in the acute medical setting: a qualitative study

Background Clinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Many guidelines are relevant to the diagnosis and management of the acutely unwell patient during the first 24–48 h of admission. Care bundles are comprised of a small number of evidence-based interventions that when implemented together aim to achieve better outcomes than when implemented individually. Care bundles that are explicitly developed from guidelines to provide a set of related evidence-based actions have been shown to improve the care of many conditions in emergency, acute and critical care settings. This study aimed to review the implementation of two distinct care bundles in the acute medical setting and identify the factors that supported successful implementation. Methods Two initiatives that had used a systematic approach to quality improvement to successfully implement care bundles within the acute medical setting were selected as case studies. Contemporaneous data generated during the initiatives included the review reports, review minutes and audio recordings of the review meetings at different time points. Data were subject to deductive analysis using three domains of the Consolidated Framework for Implementation Research to identify factors that were important in the implementation of the care bundles. Results Several factors were identified that directly influenced the implementation of the care bundles. Firstly, the availability of resources to support initiatives, which included training to develop quality improvement skills within the team and building capacity within the organisation more generally. Secondly, the perceived sustainability of changes by stakeholders influenced the embedding new care processes into existing clinical systems, maximising their chance of being sustained. Thirdly, senior leadership support was seen as critical not just in supporting implementation but also in sustaining longer-term changes brought about by the initiative. Lastly, practitioner incentives were identified as potential levers to engage junior doctors, a crucial part of the acute medical work force and essential to the initiatives, as there is currently little recognition or reward for involvement Conclusions The factors identified have been shown to be supportive in the successful implementation of care bundles as a mechanism for implementing clinical guidelines. Addressing these factors at a practitioner and organisational level, alongside the use of a systematic quality improvement approach, should increase the likelihood that care bundles will be implemented successfully to deliver evidence based changes in the acute medical setting

Time and dose dependency of bone-sarcomas in patients injected with radium-224

The time course and dose dependency of the incidence of bone-sarcomas among 900 German patients treated with high doses of radium-224 is analysed in terms of a proportional hazards model with a log-normal dependency of time to tumor and a linear-quadratic dose relation. The deduced dose dependency agrees well with a previous analysis in terms of a non-parametric proportional hazards model, and confirms the temporal distribution which has been used in the Radioepidemiological Tables of NIH. However, the linear-quadratic dose-response model gives a risk estimate for low doses which is somewhat less than half that obtained under the assumption of linearity. Dedicated to Prof. W. Jacobi on the occasion of his 60th birthday Work performed under Euratom contracts BI6-D-083-D, BI6-F-111-D, U.S. Department of Energy contract DE-AC 02-76 EV-00119, the U.S. National Cancer Institut

The reverse protraction factor in the induction of bone sarcomas in radium-224 patients

More than 50 bone sarcomas have occurred among a collective of about 800 patients who had been injected in Germany after World War II with large activities of radium-224 for the intended treatment of bone tuberculosis and ankylosing spondylitis.^In an earlier analysis it was concluded that, at equal mean absorbed doses in the skeleton, patients with longer exposure time had a higher incidence of bone sarcomas.^The previous analysis was based on approximations; in particular, it did not account for the varying times at risk of the individual patients.^In view of the implications of a reverse protraction factor for basic considerations in radiation protection, the need was therefore felt to reevaluate the data from the continued follow-up by more rigorous statistical methods.^A first step of the analysis demonstrates the existence of the reverse dose-rate effect in terms of a suitably constructed rank-order test.^In a second step of the analysis it is concluded that the data are consistent with a linear no-threshold dose dependence under the condition of constant exposure time, while there is a steeper than linear dependence on dose when the exposure times increase proportionally to dose.^A maximum likelihood fit of the data is then performed in terms of a proportional hazards model that includes the individual parameters, dose, treatment duration, and age at treatment.^The fit indicates proportionality of the tumor rates to mean skeletal dose with an added factor (1 + 0.18.tau), where tau is the treatment time in months.^This indicates that a protraction of the injections over 15 months instead of 5 months doubles the risk of bone sarcoma

The Words of War

Reporting the Civil War In this self-published work by Donagh Bracken, (he is the founder of the History Publishing Company), the author compares the Civil War battlefield reporting of the Charleston Mercury to that of the New York Times. In addition to his many corporate en...

Integrating multicultural literature into the curriculum at Pyne Poynt Family School, Camden, New Jersey

This thesis documents the importance of multicultural literature in educational environments and provides strategies for implementing the literature into the curriculum. Without the knowledge and the background of what\u27s available in this particular genre and how it can used effectively, integration of materials into the curriculum cannot occur. The African American and Hispanic American bibliographies were developed from the materials in the Pyne Poynt Family School Library to be used as teaching tools for the staff when developing resource based units of instruction and assignments. With this awareness, usage of the multicultural materials in the collection should increase over a period of time by the staff and student body

Empowering High School Students to Develop Leadership Skills and Increase Student and School Engagement

Schools that invest in building leadership capacity among students realize that learning and leading cannot be separated (Lambert, 2003). This action research study explored the developmental leadership experiences of urban minority students at Aesculapian High School in New Jersey. The study involved a learning community of 20 members from the National Honor Society and five faculty members who served as mentors. The purpose of the study was to determine what leadership skills and qualities along with learning and social needs students perceived were valuable to increase student engagement. Student leadership development was integrated into the curriculum and administered following Kouzes and Posner’s (2008) model of the Student Leadership Challenge in an effort to build leadership capacity. The conceptual framework for the study utilized the Student Leadership Challenge model in conjunction with the theories of leadership identity, student voice and meaningful student involvement as concepts for building and developing leadership in high school students to increase student engagement. This action research study provided insight into how the students constructed new knowledge and understandings about their leadership abilities utilizing data collected from qualitative surveys, instructional assessments, focus group interviews, observations, field notes and journals. The data and findings from this study documented how the student participants applied their acquired skills to become further engaged and lead other students to become involved in meaningful ways within the school environment. The study provided an understanding of how leadership skills can be effectively developed and enhanced in high school honor students and the actions produced as a result of their learning. The responsibility of initiating, developing, planning, organizing, and achieving outcomes shifted from teachers and advisors to the students, thereby labeling them leaders

Bone sarcoma cumulative tumor rates in patients injected with 224Ra

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An epidemiological assessment of lens opacifications that impaired vision in patients injected with radium-224

The incidence of lens opacifications that impaired vision (cataract) was analyzed among 831 patients who were injected with known dosages of 224Ra in Germany shortly after World War II. The dependence of the incidence on dosage, i.e., injected activity per unit body weight, and on time after treatment was determined. The observations are equally consistent with proportionality of the incidence of cataract to the square of dosage or with a linear dependence beyond a threshold of 0.5 MBq/kg. The possibility of a linear dependence without threshold was strongly rejected (P less than 0.001). The analysis of temporal dependences yielded a component that was correlated with the injected amount of 224Ra and a component that was uncorrelated. The former was inferred by a maximum likelihood analysis to increase approximately as the square of the time after treatment. The component unrelated to the treatment was found to increase steeply with age and to become dominant within the collective of patients between age 50 and 60. The relative magnitudes of the two components were such that a fraction of 55 to 60% of the total of 58 cataracts had to be ascribed to the dose-related incidence. Impaired vision due to cataract was diagnosed before age 54 in 25 cases. In terms of injected activity per unit body weight no dependence of the sensitivity on age was found; specifically there was no indication of a faster occurrence of the treatment-related cataracts in patients treated at older ages