Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth.

OBJECTIVE: To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented. DATA SOURCES: A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid∗ AND eras OR erac OR enhanced recovery. STUDY SELECTION: Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use. DATA EXTRACTION: Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents used during the hospital stay. DATA SYNTHESIS: Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results. RESULTS: Twenty-six studies were found, accounting for 19,961 individuals' experiences after ERAS implementation. Although 30% of participants experienced only scheduled cesarean births, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for opioid use and time frames. In 11 studies that reported means, the weighted average for opioid use was 54 morphine milligram equivalents per stay. In 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women. CONCLUSION: Implementation of standardized orders built on the ERAS guidelines in U.S. hospitals is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births while maintaining adequate pain relief. This review offers evidence that can support perinatal teams who are considering ERAS for cesarean birth or those looking for further improvements.

Development and validation of a questionnaire to assess the implementation of physical education programs in Chinese junior high schools.

BACKGROUND: Students' physical fitness has always been the focus of attention of the Chinese government, and the school as an important way to improve students' physical fitness, there are many studies on the current status of the implementation of physical education in schools, and there are many studies that use self-made questionnaires to investigate the implementation of physical education in schools, but most of the studies do not adequately validate the self-made questionnaires, so the purpose of this study was to develop a questionnaire to assess the level of implementation of physical education programmes in Chinese junior secondary schools and to test its reliability and validity. METHOD: The content of the questionnaire was developed based on the content of Annex 1 of the Assessment Measures for Physical Education in Primary and Secondary Schools issued by the Ministry of Education of China in 2014 and was modified based on feedback from the expert panel and pre-test participants. The questionnaire was initially tested for validity by 5 expert reviewers, and then we collected data information from 350 participants and conducted exploratory factor analysis (EFA) to explore the factor structure of the initial version. One week later, 40 of the 350 participants were randomly selected to assess test-retest reliability. RESULTS: The I-CVI and KAPPA value analysis results of the expert review results show that the questionnaire has extremely high reliability and consistency among experts. EFA results indicate that the five dimensions of this questionnaire are highly reliable. In the test-retest reliability, the Pearson correlation coefficients of the initial test data and the retest data of each dimension are all greater than 0.7, and the significance probability values are all less than 0.05, reaching the significance level, the results show that the questionnaire has good stability. CONCLUSIONS: This study concluded that the 5 dimensions and 38 items of this questionnaire had high reliability and validity and could be used as a preliminary tool to measure the implementation level of physical education programs in junior high schools in China. However, future research should explore the potential need for adjustment to suit different regions and cultures.

Early-stage implementation of peer-led interventions for emergency department patients with substance use disorder: Findings from a formative qualitative evaluation.

INTRODUCTION: Emergency department (ED)-based peer recovery coach (PRC) programs can improve access to substance use disorder treatment (SUD) for ED patients. As literature on early stages of PRC implementation is limited, we conducted a qualitative assessment of ED PRC program implementation from several US-based PRC programs focusing on barriers and facilitators for implementation and providing recommendations based on the findings. METHODS: We collected qualitative data from 39 key informants (peer recovery coaches, PRC program managers, ED physicians and staff, representatives of community-based organizations) via 6 focus groups and 21 interviews in February-December 2023. We transcribed audio-recordings and analyzed data using codebook thematic analysis. RESULTS: We identified the following major themes related to specific barriers and recommendations to address them. To facilitate timely linkage to PRCs, programs would regularly inform ED staff about the program and its linkage procedures, establish trust between PRC and ED staff, streamline the linkage procedures, and choose an "opt-out" linkage approach. To address barriers related to external referrals, programs use "warm handoff" and "warm line" strategies, maintain and update a comprehensive catalog of resources, and familiarize peer coaches with local service providers. Telehealth services implementation requires addressing logistical barriers, ensuring patients' privacy, and training peer coaches on building trust and rapport online. Peer coaches' wellness and quality of services can be improved by limiting PRC's workload, prioritizing quality over quantity, facilitating self-, peer- and professional care to mitigate stress and burnout; and, importantly, by providing supportive supervision and training to peer coaches and advocating for PRC team as an equal partner in the ED settings. To facilitate PRC program adoption and sustainment program managers engage local communities and program champions, seek diverse sources of funding, and advocate for structural changes to accommodate recruitment and retention of peer recovery coaches. CONCLUSIONS: We compiled a wealth of best practices used by PRC programs to address numerous implementation barriers and challenges. These recommendations are intended for PRC program planners, managers and champions, hospital leadership, and state and local public health agencies leading SUD epidemic response.

Prevalence, Best Practice Use, and Member Engagement on School Mental Health Teams.

School mental health (SMH) teams have been widely recommended to support multi-tiered mental health program implementation in schools. Available research suggests emerging best practices that promote effective SMH teaming and indicates the importance of having team members who are highly engaged (e.g., actively involved, retained on the team). Despite evidence that these factors improve team functioning, there is limited knowledge of SMH team prevalence, best practice use, and factors impacting member engagement among a diverse sample of elementary schools. This study surveyed a cross-sectional sample of elementary principals (n = 314) across the United States whose schools implement multi-tiered SMH programs. Most principals (89%, n = 280) reported using teams to organize these programs. Schools in urban/suburban communities, with 300 or more students, or with specific school funding for SMH activities were more likely to have SMH teams. Only one-third of principals reported that their team members participated in related training. Other SMH team best practices were commonly reported (by two-thirds or more teams). Results of a linear regression model indicate that larger teams (six or more members) and teams with access to resources had significantly higher member engagement scores. The study's findings provide recommendations for practice and future research directions.

Making the leap from idea generation to implementation: Ten steps every geriatrics specialist should know.

This is an exciting time in Geriatrics, with numerous opportunities in health care for Geriatrics specialists to innovate and lead. Geriatrics specialists should know how to implement innovative care models to lead healthcare changes in their organizations and effectively facilitate change management. We highlight a 10-step framework that Geriatrics specialists can leverage to quickly move their ideas from development to implementation at a system level. This framework adapts concepts from business management to provide a step-by-step guide to move from idea generation to implementation. We provide different practical examples that a Geriatrician can correlate to in their practice, including value proposition and business canvas model. Though small components of the business canvas model may vary based on organization and program/idea-specific needs, the outlined skills will establish Geriatrics specialists as leaders of change, a resource for education, and valued consultants to a health system that is in dire need of direction to improve the quality of care, and health outcomes, for older adults.

A Review of Public Sector Engagement in Age-Friendly Community Initiatives.

The global age-friendly cities and communities (AFCC) movement has centered on the involvement of the public sector, calling on high-ranking authorities to commit to improving the built, social, and service environments of their localities. This interpretive review aimed to advance understanding of the ways in which the public sector is involved in AFCC efforts. Based on emergent themes from peer-reviewed articles from the United States and Canada published since 2010, we derived a two-dimensional framework for conceptualizing variability in public sector involvement, encompassing the internal/external (a) locus of responsibility for cross-sector change and (b) target for cross-sector change. We discuss implications for research, policy, practice, and further knowledge development in AFCC implementation.

Factors Influencing Participation and Engagement in a Teen Safe Driving Intervention: A Qualitative Study.

(1) Background: Few teen driving safety programs focus on increasing parental engagement with high-risk teen drivers, specifically those with a traffic violation. This study explored parents'/guardians' ('parents') experiences with a teen driving safety program, ProjectDRIVE, including facilitators and barriers to program engagement. (2) Methods: We conducted virtual, semi-structured interviews with parents who completed ProjectDRIVE, which included in-vehicle driving feedback technology and individualized virtual training with parents on effective parent-teen communication. (3) Results: Twenty interviews (with 17 females and three males) were transcribed verbatim and independently coded by three coders using systematic, open, and focused coding. Three major themes were identified: factors influencing a parent's initial decision to participate, factors influencing continued engagement, and perceived benefits of participation. The decision to participate was influenced by these subthemes: parental motivation to help their teen, perceived program usefulness, program endorsement, program incentives, parents' busy schedules, and lack of access to a car/internet. Subthemes impacting continued engagement included enhanced communication skills, teen willingness to engage, strong parental engagement, and teens' other priorities. Perceived benefits included greater self-efficacy in communication, improved communication patterns and frequency, and enhanced parent-teen relationships. (4) Conclusions: These findings may set the foundation for developing and implementing future court-ordered parent-based teen safe driving programs for teens with traffic citations.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland.

Objective: To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust. Methods: We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate. Results: Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups. Conclusion: Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

Implementing a robotic hepatopancreatobiliary program for new faculty: safety, feasibility and lessons learned.

Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data are available about how this translates into successful incorporation in faculty practice. All operations performed during the first three years of practice of a surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, a metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative time benchmarks. The major complications, defined as a Clavien-Dindo of 3 or more, were similar across the experience and comparable to published series. Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.

Implementing a Robotic Hepatopancreatobiliary Program for New Faculty: Safety, Feasibility and Lessons Learned.

Background: Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data is available about how this translates into successful incorporation in faculty practice. Methods: All operations performed during the first three years of practice of a complex general surgical oncology-trained surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. Results: 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, the optimal metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative times. Major complications were similar across the experience and comparable to published series. Conclusion: Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.

Addressing Bioethical Implications of Implementing Diversion Programs in Resource-Constrained Service Environments.

The opioid epidemic demands the development, implementation, and evaluation of innovative, research-informed practices such as diversion programs. Aritürk et al. have articulated important bioethical considerations for implementing diversion programs in resource-constrained service environments. In this commentary, we expand and advance Aritürk et al.'s discussion by discussing existing resources that can be utilized to implement diversion programs that prevent or otherwise minimize the issues of autonomy, non-maleficence, beneficence, and justice identified by Aritürk et al.

Validity Evidence for an Observational Fidelity Measure to Inform Scale-Up of Evidence-Based Interventions.

As evidence-based interventions are scaled, fidelity of implementation, and thus effectiveness, often wanes. Validated fidelity measures can improve researchers' ability to attribute outcomes to the intervention and help practitioners feel more confident in implementing the intervention as intended. We aim to provide a model for the validation of fidelity observation protocols to guide future research studying evidence-based interventions scaled-up under real-world conditions. We describe a process to build evidence of validity for items within the Session Review Form, an observational tool measuring fidelity to interactive drug prevention programs such as the Botvin LifeSkills Training program. Following Kane's (2006) assumptions framework requiring that validity evidence be built across four areas (scoring, generalizability, extrapolation, and decision), confirmatory factor analysis supported the hypothesized two-factor structure measuring quality of delivery (seven items assessing how well the material is implemented) and participant responsiveness (three items evaluating how well the intervention is received), and measurement invariance tests suggested the structure held across grade level and schools serving different student populations. These findings provide some evidence supporting the extrapolation assumption, though additional research is warranted since a more complete overall depiction of the validity argument is needed to evaluate fidelity measures.

The NICHE Coordinator: A key leadership role in the NICHE practice model.

This month we focus on the role of the NICHE Coordinator, who leads NICHE program activities to advance the use of evidence-based practices that improve the quality and safety of care delivered to older adults in healthcare delivery settings. We present a new leadership development class for NICHE Coordinators to enhance their overall effectiveness with implementing the NICHE practice model in their organizations.

Determinants of Bluetooth-Enabled Self-Measured Blood Pressure Monitoring in Federally Qualified Health Centers.

BACKGROUND: In 2021, the Health Resources and Services Administration (HRSA) launched the National Hypertension Control Initiative (HTN Initiative) with the goal to enhance HTN control through Bluetooth-enabled self-measured blood pressure (BT-SMBP) monitoring and use this data to inform clinical decisions in Federally Qualified Health Centers (FQHCs) with a large proportion of their population with uncontrolled blood pressure (BP). We sought to understand the experience of Michigan-based FQHCs in implementing the HTN initiative. METHODS: Staff from three Michigan-based FQHCs were invited to participate in semi-structured interviews from September to November 2022. Interviews were conducted in-person and were based on the Tailored Implementation in Chronic Diseases framework. Content analysis was performed by three coders. RESULTS: Ten staff participated in interviews (FQHC 1: n = 6, FQHC 2: n = 1, FQHC 3: n = 3). The FQHCs differed in their stage of implementation and their approach. FQHC 1 created a large-scale, community health worker driven program, FQHC 2 created a small-scale, short term, BP device loan program, and FQHC 3 created a primarily outsourced, large-scale program through a contracted partner. Positive staff attitudes and outcome expectations, previous experience with SMBP grants, supportive clinic leadership, social support, and free BP cuff resources were identified as facilitators to implementation. Patients' high social needs, SMBP-related Technology, and insufficient workforce and staff capacity were identified as barriers. CONCLUSION: BT-SMBP among FQHC patients is promising but challenges in integrating SMBP data into clinic workflow, workforce capacity to support the high social needs of participants, and to assist in reacting to the more frequent BP data remain to be overcome.

Bridging Hospital and Nursing Home: Collaboration for Smoother Transitions and Reduced Hospitalizations.

The exigencies of managing acutely ill residents within nursing homes have led to an increase in ambulance conveyances to the emergency department. This is further compounded by a shortage of adequately trained nursing staff and on-site physicians available around the clock. An acute regional hospital, strategically located in the epicenter of nursing home facilities in Singapore, encountered this challenge on its inception in 2018 within the northeast region. In response, the institution initiated a collaboration, EAGLEcareACT (Enhancing Advance Care Planning, Geriatrics, and End-of-Life Care Acute Care Team), aimed at rectifying the prevailing care disparities between neighboring nursing homes and the hospital. Within the EAGLEcareACT, a systematic and comprehensive approach was undertaken to engage diverse nursing homes, delineate precise needs, and establish mutually shared objectives. This encompassed the provisioning of monitoring of patients treated for acute medical conditions, structured training programs for nursing staff and aids in advance care planning. Teleconsultations with EAGLEcareACT team obviate the immediate necessity for conveyance to the emergency department.

Establishing a robust radioligand therapy program: A practical approach for North American centers.

Radioligand therapy (RLT) is a targeted approach to treating cancer that has been shown to be safe and effective in a variety of disease states, including gastroenteropancreatic neuroendocrine tumors, lymphoma, and most recently, advanced prostate cancer. In the United States, patient access to this therapy is currently variable. Implementation of new RLT programs and expansion of existing programs are needed to broaden patient access to and standardize the delivery of RLT, especially as new therapies are introduced into clinical practice. Drawing from experience in establishing RLT programs in different settings, we have developed practical recommendations for building and implementing a robust RLT program. In this review, we present our recommendations for minimal requirements and optimal requirements, as well as system considerations, and special issues associated with implementing an RLT program in North American centers.

Implementing a sexual violence prevention program in two Canadian Indigenous communities: Challenges and lessons learned.

BACKGROUND: The prevalence of child sexual violence remains overwhelming, particularly among Indigenous populations, despite increased awareness. Therefore, implementing efficient initiatives is crucial in preventing and reducing sexual violence rates among these groups. OBJECTIVE: This study aimed to examine the processes involved in the implementation of a sexual violence prevention program in two Indigenous communities in Canada and assess application of culturally safe practices. METHOD: Eight Indigenous and non-Indigenous project managers underwent semi-structured interviews before the program's implementation; five of them also participated in the follow-up interviews. Moreover, thirteen Indigenous service providers from the two communities answered open-ended questions when the included training ended. RESULTS: Thematic analysis revealed the importance of following an ongoing process (not only before implementing a program) to assess the needs of community members and involving them in decision-making. Administrative injunctions were also identified as a significant challenge during implementation. Results showed that participants reported the taboo of sexual violence as a challenge but that constant discussions about the prevention of sexual violence helped defuse the discomfort and foster trust between Indigenous and non-Indigenous professionals. Finally, participants provided recommendations to improve research and intervention practices. CONCLUSIONS: Several takeaways were discussed to improve research practices with, by, and for Indigenous peoples, such as using collaborative communication, developing common understanding relative to work agendas, and increasing cultural competencies to build trust within the partnership.

The Development and Implementation of a School-Based Dental Sealant Program for Hawaii Public Schools.

BACKGROUND: School-based dental sealant programs are noted to increase sealant uptake among children, especially those from low-income families and those living in rural and underserved areas. However, nationally school-based dental sealant programs are substantially underutilized. This paper describes a partnership approach to a school-based dental sealant program for Title 1 public schools in Hawaii. METHODS: The Hawaii Keiki: Healthy and Ready to Learn program partnered with the Hawaii Dental Service to develop and implement an interprofessional, school-based sealant program (SBSP). This article describes the development of key factors, such as partnerships, an interprofessional team, team roles, policies, and marketing tools to optimize program success. RESULTS: The SBSP has completed over 3 academic years of implementation in Hawaii public schools. In its initial year (school year [SY] 2019-2020), which presented challenges due to the COVID-19 pandemic, it served 6 schools (106 students screened) on 1 island. It expanded to 14 schools on 1 island (193 students screened) in its second year (SY 2020-2021), 28 schools on 3 islands (653 students screened) in its third year (SY 2021-2022), and during the Fall of the fourth year, the program reached 50 schools on 3 islands (1821 students screened) and is projected to reach over 70 schools by the end of SY 2022-2023. CONCLUSION: Taking advantage of strategic partnerships and key interprofessional team members, a school-based dental sealant program can help to improve the oral health of children in public schools by helping to decrease barriers to care.

Perspectives on implementing Individual Placement and Support (IPS) within primary health care settings for adults living in British Columbia, Canada.

BACKGROUND: Individual placement and support (IPS) is an evidence-based practice (EBP) designed to help people with severe mental illness re-enter the labour market. Implementing an IPS program within a new context (e.g., primary health care setting) to support populations that are complex and multi-barriered presents a set of unique challenges and considerations. This paper provides community-based perspectives that identify implementation strengths and challenges and highlights potential strategies aimed at addressing emergent barriers. METHODS: A case study was conducted across three community health centres in British Columbia (BC), Canada, where a novel IPS program was embedded within primary care services. Data collection consisted of open-ended surveys and focus groups with service providers directly involved in program implementation and their associated clinical and managerial support teams (n = 15). Using the updated Consolidated Framework for Implementation Research (CFIR) as a guide, we performed deductive thematic analysis to identify key areas impacting IPS implementation. RESULTS: Integration with existing health care systems and primary health care teams and support from leadership across all levels were identified as both key facilitators and barriers to implementation. Facilitators and barriers were identified across all domains, with those within innovation and process most easily addressed. Four cross-cutting themes emerged for promoting more integrated and sustainable program implementation: investing in pre-implementation activities, supporting a dynamic and flexible program, building from community experiences, and developing a system for shared knowledge. CONCLUSIONS: Implementing an IPS program embedded within primary health care settings is complex and requires extensive planning and consultation with community-based service providers and decision-makers to achieve full integration. Future practice and policy decisions aimed at supporting employment and well-being should be made in collaboration with communities.

Which Program Implementation Factors Lead to more Fruit and Vegetable Purchases? An Exploratory Analysis of Nutrition Incentive Programs across the United States.

Background: Nutrition incentive (NI) programs help low-income households better afford fruits and vegetables (FVs) by providing incentives to spend on FVs (e.g., spend $10 to receive an additional $10 for FVs). NI programs are heterogeneous in programmatic implementation and operate in food retail outlets, including brick-and-mortar and farm-direct sites. Objective: This study aimed to explore NI program implementation factors and the amount of incentives redeemed. Methods: A total of 28 NI projects across the United States including 487 brick-and-mortar and 1078 farm-direct sites reported data between 2020 and 2021. Descriptive statistics and linear regression analyses (outcome: incentives redeemed) were applied. Results: Traditional brick-and-mortar stores had 0.48 times the incentives redeemed compared with small brick-and-mortar stores. At brick-and-mortar sites, automatic discounts had 3.47 times the incentives redeemed compared with physical discounts; and auxiliary services and marketing led to greater redemption. Farm-direct sites using multilingual and direct promotional marketing had greater incentives redeemed. Conclusions: To our knowledge, this is the first national study to focus on NI program implementation across sites nationwide. Factors identified can help inform future programming and research.