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

A study to evaluate the effect of subcutaneous infiltration of ketamine at incisional site on post operative analgesia in patients undergoing abdominal hysterectomy under spinal anaesthesia

Background: Postoperative pain is often perceived by patient as natural consequences of surgery. If poorly treated it triggers neuroendocrine stress response which may increase morbidity and mortality. Ketamine acts as non-competitive antagonist at NMDA receptors having local analgesic effect. If given subcutaneously the side effects are significantly lower. Aims and Objectives: To evaluate the analgesic effects of subcutaneous infiltration of ketamine at incisional site in elective abdominal hysterectomy under spinal anaesthesia. Materials and Methods: Fifty patients of ASA physical status 1 & 2 aged 35-60 years undergoing abdominal hysterectomy were allocated into two groups as group K and group C, using computer generated random number list each consisting 25 patients (n=25), group K received ketamine 0.5mg/kg subcutaneously and group C 0.9% normal saline subcutaneously in surgical wound site post operatively. Patients were monitored at 0 minutes, 30 minutes,1,2,4,6,8,12,16,20,24 hours interval for changes in HR, BP, SPO2,VAS. Also side effects if any are noted. Time for the first request for analgesia and total amount of rescue analgesic consumed in 24 hours noted and compared between both groups statistically. Results: The time for first request for analgesia in group C was 149.60+7.27 minutes whereas it was longer in group K 245.80+15.27minutes (P<0.001), the mean VAS scores in group K at 2,4,6,8, and 12 hours was less compared to group C recorded during same time interval, which is statistically significant and the total amount of rescue analgesia consumed during 24 hours in group C was 86.0+30.69 whereas in group K it was 46+24.66.significantly lower in group K compared to group C(P<0.001). Conclusion: Patient who were given ketamine subcutaneously at incision site postoperatively had lower pain intensity and less analgesic consumption than patients who were given placebo without increase in the risk of complications

Finding Dental Harm to Patients through Electronic Health Record–Based Triggers

BackgroundPatients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs).MethodsWe developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs.ResultsOf the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room.ConclusionBy developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future.Knowledge transfer statementA retrospective review of patients' health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record-based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered