"Struggling with practices" - A qualitative study of factors influencing the implementation of clinical quality registries for cardiac rehabilitation in England and Denmark

Background: The use of clinical quality registries as means for data driven improvement in healthcare seem promising. However, their use has been shown to be challenged by a number of aspects, and we suggest some may be related to poor implementation. There is a paucity of literature regarding barriers and facilitators for registry implementation, in particular aspects related to data collection and entry. We aimed to illuminate this by exploring how staff perceive the implementation process related to the registries within the field of cardiac rehabilitation in England and Denmark. Methods: A qualitative, interview-based study with staff involved in collecting and/or entering data into the two case registries (England N = 12, Denmark N = 12). Interviews were analysed using content analysis. The Consolidated Framework for Implementation Research was used to guide interviews and the interpretation of results. Results: The analysis identified both similarities and differences within and between the studied registries, and resulted in clarification of staffś experiences in an overarching theme: Struggling with practiceś and five categories; the data entry process, registry quality, resources and management support, quality improvement and the wider healthcare context. Overall, implementation received little focused attention. There was a lack of active support from management, and staff may experience a struggle of fitting use of a registry into a busy and complex everyday practice. Conclusion: The study highlights factors that may be important to consider when planning and implementing a new clinical quality registry within the field of cardiac rehabilitation, and is possibly transferrable to other fields. The results may thus be useful for policy makers, administrators and managers within the field and beyond. Targeting barriers and utilizing knowledge of facilitating factors is vital in order to improve the process of registry implementation, hence helping to achieve the intended improvement of care processes and outcomes

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guidelines´ aim of uniform, evidence-based content of CR services across settings

In-hospital patient safety - prevention of deterioration and unexpected death by systematic and interprofessional use of early warning scoring

Abstract In-hospital patient safety is at times hampered, leaving general ward patients at considerable risk of gradual, even life-threatening, deterioration. In many European clinical settings, inappropriate nursing practice of bedside monitoring and management has recently been addressed as impending to in-hospital patient safety. Vital parameters have for two decades been known to deviate in individual patients hours ahead of serious adverse events, but this knowledge has not yet been generally rooted among nursing and medical in-hospital staff, contributing to misinterpretation of individual vital signs and inadequate bedside action being taken. Accordingly, this knowledge of the predictable value of deviations in bedside vital parameters has not until recently been reflected in general ward patient monitoring practice. A clinical multi-component intervention comprising mandatory nursing bedside monitoring, based on structured regular in-hospital use and recording of modified early warning scores in in-hospital patients, was implemented by structured interprofessional teaching, training and promotion in a large medical and surgical study setting at an urban Scandinavian university hospital. This thesis has been based on four non-randomized pre- and postinterventional studies on bedside practice in this context (I-IV). Outcome measures of particular interest were associations between early deviation in various vital parameters and later severe deterioration (IV), and potential effects of the study intervention on unexpected death (III). Before implementation of the study intervention, nursing monitoring practice was found to be influenced mainly by individual levels of professionalism, characterized by knowledge, reflection, and interprofessional collaboration (I). After this implementation, the three most common bedside vital parameters were found to be recorded more frequently (II), and the unexpected in-hospital patient mortality in the study setting to be significantly lower (III), than before. Moreover, the medical emergency team was called in three times more often (III). Three quarters of the patients were rescored within the time limits of eight and four hours stated in the algorithm of bedside management (II). Sudden tachycardia or tachypnea in slightly deteriorated, particularly older, in-hospital patients was found to be significantly associated with later severe clinical deterioration (IV)

Impact of professionalism in nursing on in-hospital bedside monitoring practice.

AIM: This article reports a study exploring nursing practice of monitoring in-hospital patients including intra- and interprofessional communication and collaboration. BACKGROUND: Sub-optimal care in general in-hospital wards may lead to admission for intensive care, cardiac arrest, or sudden death. Reasons may include infrequent measurements of vital parameters, insufficient knowledge of their predictive values, and/or sub-optimal use of Medical Emergency Teams. This study was designed to improve understanding of nursing practice and to identify changes required to support nursing staff in improving standards of clinical monitoring practice and patient safety in general in-hospital wards. DESIGN: The study was designed as a qualitative descriptive clinical study, based on method triangulation including structured individual observations and semi-structured individual interviews. METHODS: In the spring of 2009, structured observations and semi-structured interviews of 13 nurses were carried out at a university hospital in Copenhagen, Denmark. The observational notes and interview transcriptions were analysed using content analysis. RESULTS: One theme (Professionalism influences nursing monitoring practice) and two sub-themes (Knowledge and skills and Involvement in clinical practice through reflections) were identified. Three categories (Decision-making, Sharing of knowledge, and Intra- and interprofessional interaction) were found to be associated with the theme, the sub-themes, and with each other. CONCLUSION: Clinical monitoring practice varies considerably between nurses with different individual levels of professionalism. Future initiatives to improve patient safety by further developing professionalism among nurses need to embrace individual and organizational attributes to strengthen their practice of in-hospital patient monitoring and management

The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs : A retrospective medical record review study

Aims and objectives: To evaluate whether the scale used for assessment of hospital ward patients could predict in-hospital and 30-day mortality amongst those with deviating vital signs; that is, that patients classified as medium or high risk would have increased risk of in-hospital and 30-day mortality compared to patients with low risk. Background: The National Early Warning Score (NEWS) is a widely adopted scale for assessing deviating vital signs. A clinical risk scale that comes with the NEWS divides the risk for critical illness into three risk categories, low, medium and high. Design: Retrospective analysis of vital sign data. Methods: Logistic regression models for age-adjusted in-hospital and 30-day mortality were used for analyses of 1,107 patients with deviating vital signs. Results: Patients classified as medium or high risk by NEWS experienced a 2.11 or 3.40 increase, respectively, in odds of in-hospital death (95% CI: 1.27–3.51, p = 0.004% and 95% CI: 1.90–6.01, p < 0.001) compared to low-risk patients. Moreover, those with NEWS medium or high risk were associated with a 1.98 or 3.19 increase, respectively, in odds of 30-day mortality (95% CI: 1.32–2.97, p = 0.001% and 95% CI: 1.97–5.18, p < 0.001). Conclusion: The NEWS risk classification seems to be a reliable predictor of mortality on patients in hospital wards. Relevance to clinical practice: The NEWS risk classification offers a simple way to identify deteriorating patients and can aid the healthcare staff to prioritise amongst patients

Mandatory early warning scoring-implementation evaluated with a mixed-methods approach.

The aim of this study was to evaluate adherence to an intervention optimizing in-hospital monitoring practice, by introducing early warning scoring (EWS) of vital parameters