Working to improve survival and health for babies born very preterm: The WISH project protocol

Background: Babies born very preterm (before 30 weeks gestation) are at high risk of dying in their first weeks of life, and those who survive are at risk of developing cerebral palsy in childhood. Recent high-quality evidence has shown that giving women magnesium sulphate immediately prior to very early birth can significantly increase the chances of their babies surviving free of cerebral palsy. In 2010 Australian and New Zealand clinical practice guidelines recommended this therapy. The WISH (Working to Improve Survival and Health for babies born very preterm) Project aims to bi-nationally improve and monitor the use of this therapy to reduce the risk of very preterm babies dying or having cerebral palsy. Methods/Design: The WISH Project is a prospective cohort study. The 25 Australian and New Zealand tertiary level maternity hospitals will be provided with a package of active implementation strategies to guide the introduction and local adaptation of guideline recommendations. Surveys will be conducted at individual hospitals to evaluate outcomes related to local implementation progress and the use and value of the WISH implementation strategies. For the hospitals participating in the ‘WISH audit of uptake and health outcomes data collection’, the primary health outcomes (assessed through case note review, and 24 month corrected age questionnaires) will be: the proportion of eligible women receiving antenatal magnesium sulphate; and rates of death prior to primary hospital discharge and cerebral palsy at two years corrected age in infants born to eligible mothers. For hospitals wishing to assess factors influencing translation locally, barriers and facilitators will be measured through interviews with health care professionals, to further guide implementation strategies. Study outcomes for the early phase of the project (Year 1) will be compared with the later intervention phase (Years 2 and 3). Discussion: The WISH Project will offer insight into the effectiveness of a multifaceted implementation strategy to improve the uptake of a novel neuroprotective therapy in obstetric clinical practice. The successful implementation of antenatal magnesium sulphate for fetal neuroprotection in Australia and New Zealand could lead to over 90 fewer very preterm babies dying or suffering the long-term consequences of cerebral palsy each year.Caroline A Crowther, Philippa F Middleton, Emily Bain, Pat Ashwood, Tanya Bubner, Vicki Flenady, Jonathan Morris, Sarah McIntyre for the WISH Project Tea

Facilitating technology adoption in the NHS : negotiating the organisational and policy context : a qualitative study

Background: Proven clinical effectiveness and patient safety are insufficient to ensure adoption and implementation of new clinical technologies. Despite current government policy, clinical technologies are not yet demand-led through commissioning. Hence, adoption and implementation relies on providers. Introducing new technologies initially raises providers’ costs as they necessitate training, alter patient pathways and change patient management, and may lead to reduced patient throughput in the short term. The current funding regime for providers – Payment by Results (PbR) – rewards activity. It is not surprising, therefore, that providers often see new technologies as risky. Objectives: This study investigated the organisational and policy context for the adoption and implementation of clinical technologies, because this context may present barriers that slow – or even prevent – uptake. The research focused on three clinical technologies: insulin pump therapy (IPT); breast lymph node assay (BLNA), a diagnostic tool for metastases; and ultrawide field retinal imaging (UFRI). The implementation of these technologies had been supported by NHS Technology Adoption Centre (NTAC). Methods: The research method was qualitative case studies of these three clinical technologies. The primary data collection technique was semistructured interviews of NTAC staff, clinicians, managers and commissioners, supplemented by documentary evidence, participant and non-participant observation of meetings and videos. For IPT, we also conducted a survey of clinicians and analysed anonymised e-mails from patients. Results: NHS providers did not perceive any central ‘push’ from the Department of Health or the National Institute for Health and Care Excellence (NICE) to adopt, implement or diffuse new clinical technologies. There is a ‘bottom-up’ adoption culture: any trust could choose to adopt any, all or none of the three clinical technologies we investigated. This is undesirable, as clinically efficacious technologies should be equally available to all patients. Where there is NICE guidance, this acted as an enabler for adoption, but some trusts still did not offer IPT despite this. We found that PbR could be a major obstacle to adoption. Our evidence also indicates that, contrary to its intention, commissioning practice is more of a barrier than an enabler of innovation. Protracted negotiations over funding between providers and commissioners delayed implementation of BLNA and IPT. Organisational power and politics between hospitals and community-based services was a significant barrier for adoption of UFRI. Clinicians outside of specialist ophthalmology centres did not understand the clinical utility of UFRI (e.g. its diagnostic potential or how and when to use it). Conclusions: NTAC was successful in assisting trusts over the generic organisational barriers outlined above, particularly with regard to taking responsibility for the logistics of implementation, negotiating new patient pathways and ways of working with relevant stakeholders, and using their skills in project management and stakeholder engagement to drive processes forward. Where there were major obstacles, however, the NTAC process stalled. ‘Bottom-up’ adoption at individual trusts needs to be linked into wider national processes that offer vision, some central direction, further assessment and evaluation, and the infrastructure to ensure diffusion to sites that have the capabilities and capacities to best utilise the clinical technology

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes education in children and adolescents.

RECOMMENDATIONS/EXECUTIVE SUMMARY Education is the key to successful management of diabetes [E]. To maximize the effectiveness of diabetes treatment and the advances in diabetes management and technology (especially insulin pumps and continuous glucose monitoring) it is advisable that quality assured structured education is available to all young people with diabetes and their carers [E]. The content and delivery of structured education needs regular review to ensure it suits the needs of people with diabetes in that community, matches local practice, and reflects changes in diabetes management and technology [E]. Evaluation of structured educational programs should include measurement of outcomes directly related to diabetes education such as the patient\u27s achievement of self‐selected diabetes‐care goals, improved psychosocial adaptation and enhanced self‐efficacy, in addition to measures of glycemic control [E]. There is evidence that educational interventions in childhood and adolescent diabetes have a beneficial effect on glycemic and psychosocial outcomes [A]. Educational interventions shown to be effective include those: based on clear theoretical psychoeducational principles [E] integrated into routine clinical care (eg, as an essential integral part of intensive insulin management) [A] referred to as an ongoing process of provision of individualized self‐management and psychosocial support [E] involving the continuing responsibility of parents and other carers throughout adolescence [B] making use of cognitive behavioral techniques most often related to problem solving, goal setting, communication skills, motivational interviewing, family conflict resolution, coping skills, and stress management [A] utilizing new technologies in diabetes care as one of the vehicles for educational motivation [A] Health care professionals require appropriate specialized training in the principles and practice of teaching and education to implement successfully behavioral approaches to education designed to empower young people and carers in promoting self‐management [E]. An interdisciplinary education team sharing the same philosophy and goals and speaking “with one voice” has beneficial effects on metabolic and psychosocial outcomes [B]. It is important that goals and targets for blood glucose and HbA1c align with those of ISPAD. A major task during the first 2 weeks after diagnosis of diabetes is to get the family to agree to encompass the same targets. [E] Mobile and web‐based applications can be useful tools for diabetes self‐management education to improve diabetes management. [E] Interactive web‐based educational resources designed by diabetes‐related device manufacturing companies are widely used for device‐specific patient training and education. [E] Telemedicine, if available, offers an alternative method to face‐to‐face diabetes review for people who live in remote areas and do not have access to professional counseling and diabetes education resources locally. [B] Diabetes peers and/or diabetes youth leaders can reinforce the principles of living well with diabetes and support the families learning especially in the resource limited setting. [E