Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

BACKGROUND: Disseminating new safe practices has proved challenging. In a statewide initiative we developed a framework for (1) selecting two safe practices, (2) developing operational details of implementation, (3) enlisting hospitals to participate, and (4) facilitating implementation. METHODS: Potential topics were selected by a multistep process to identify candidate practices, review the evidence for efficacy and feasibility, and then select them on the basis of importance, efficacy, feasibility, and impact. A multi-stakeholder advisory group representing all constituencies selected two practices: reconciling medications (RM) and communicating critical test results (CTR). Operational details and strategies for implementation were then developed for each practice using a consensus process of discipline stakeholders led by content experts. Hospital CEOs were solicited to participate by the Massachusetts Hospital Association which made the project a "flagship" initiative. A collaborative model was used to facilitate implementation, following the IHI Model for Improvement. In addition to providing exposure to content and method experts, we gave teams a "toolkit" containing recommendations, a change package, and implementation strategies. Each collaborative met four times over an 18 month period. Results were assessed using the IHI team assessment scale and surveys of teams and hospital leaders. RESULTS: Hospital participation rate was high with 88% of hospitals participating in one or both collaboratives. Partial implementation of the practices was achieved by 50% of RM teams and 65% of CTR teams. Full implementation was achieved by 20% of teams for each. CONCLUSIONS: Major factors leading to hospital participation included the intrinsic appeal of the practices, access to experts, and the availability of implementation strategies. Team success was correlated with active engagement of a senior administrator, engagement of physicians, increased use of PDSA cycles, and attendance at collaborative meetings. The prior development of subpractices, recommendations and implementation strategies was essential for the hospital teams. These should be well worked out before hospitals are required to implement any guideline.

Applause for Sydney Hospital Unit.

With hand injuries representing a significant proportion of occupational trauma, nurses at Sydney Hospital's Hand Unit were given the green light for their education program.

Age-related responses to stimulation of cardiopulmonary receptors in swine.

Cardiovascular responses to stimulation of cardiopulmonary receptors were evaluated in standard breed developing swine (1-2 days, 1-2 wk, and 2 mo of age) and sexually mature miniswine anesthetized with 0.25-0.50% halothane in O2. Cryptenamine, a mixture of veratrum viride alkaloids (VVA), was administered as right atrial or left ventricular bolus injections in doses of 5-20 micrograms/kg. In developing swine, mean aortic pressure (AoP) decreased after 10-20 micrograms/kg VVA in 1- to 2-wk olds and after 5-20 micrograms/kg VVA in 2-mo olds. Bradycardia was always elicited. Renal (Ren) and femoral (Fem) vasodilation occurred in the 1- to 2-wk-old and 2-mo-old groups after 5-20 micrograms/kg VVA. Mesenteric (Mes) vasodilation was elicited with 10-20 micrograms/kg VVA in the 1- to 2-wk-old group and with 5-20 micrograms/kg VVA in 2-mo olds. In the 1- to 2-day-old group, VVA did not significantly alter Ren, Fem, and Mes vascular resistance. In mature miniswine, 20 micrograms/kg VVA elicited decreases in AoP and heart rate that were similar in magnitude to responses obtained with only 5 micrograms/kg VVA in dogs. Cardiovascular responses to VVA were abolished after bilateral vagotomy but were not altered after denervation of the carotid sinuses. The results indicate postnatal maturation of the Bezold-Jarisch reflex in swine.

Cardiovascular responses to arterial and venous hemorrhage in neonatal swine.

The cardiovascular effects of graded arterial or venous hemorrhage were evaluated in developing swine (less than or equal to 1 day, 2-5 days, 1 wk, and 2 wk of age) anesthetized with halothane in 50% N2O-50% O2. Serial 5-ml/kg aliquots of arterial or venous blood were removed at 3- to 4-min intervals to a cumulative total of 20 ml/kg. Tachycardia occurred in most animals. Decreases in aortic pressure to arterial, but not to venous, hemorrhage were age dependent. Renal, femoral, and carotid arterial flows decreased with hemorrhage in all animals; the decreases in blood flow did not differ among the three circulations and were not age dependent. Increases in femoral resistance were obtained to both arterial and venous hemorrhage only in the 2-wk-old group. As the degree of hemorrhage was increased, aortic pressure, regional blood flow, and femoral resistance (2 wk olds) responses were larger in magnitude. Aortic pressure in piglets 1-5 days of age could not be restored to within 20% of the prehemorrhage level at a smaller bleeding volume with arterial than with venous hemorrhage. Pressor responses to norepinephrine (0.5 micrograms/kg) and to bilateral common carotid occlusion were still present after 20-ml/kg hemorrhage. These responses indicate the presence of a progressive maturation-related compensation to the stress of arterial but not venous hemorrhage.

Cardiac effects of esophageal stimulation: possible relationship between gastroesophageal reflux (GER) and sudden infant death syndrome (SIDS).

Twenty-six artificially ventilated newborn pigs were subjected to simulated gastroesophageal reflux; saline (10 cc) of varying pH was flushed through the esophagus from below. At a given pH threshold, reflex bradycardia, which could be blocked by atropine, was elicited. Transecting of the superior laryngeal nerves, the recurrent laryngeal nerves, and the pharyngeal plexus nerves did not block the reflex bradycardia. However, bypassing the regions superior to the esophagus with a shunt prevented the bradycardia. These results indicate that bradycardia caused by gastroesophageal reflux is independent of changes in ventilation and may be an important cause of sudden infant death.

Maturation-related differences in regional circulatory effects of dopamine infusion in swine.

The cardiovascular effects of dopamine (DPA) infusions were evaluated in developing swine, less than or equal to 1 day, 2 weeks, and 2 months of age, anesthetized with halothane in 50% N2O and O2. DPA was given by intravenous infusion in randomized doses of 2, 5, 10 and 20 micrograms/kg/min for 10 min. Depressor responses and bradycardia were observed during 2 micrograms/kg/min in 2-week-olds and during 2, 5 and 10 micrograms/kg/min in 2-month-olds. During infusion of 20 micrograms/kg/min, DPA pressor responses were observed in animals less than or equal to 2 weeks of age; in addition, tachycardia occurred in 1-day-old swine. Renal resistance decreased during infusion of 2 micrograms/kg/min in all swine. It increased during 10 and 20 micrograms/kg/min in the 1-day and 2-week groups, but not in the 2-month group. Mesenteric resistance decreased during infusion of 2, 5 and 10 micrograms/kg/min in less than or equal to 2-week-olds and at all doses in 2-month-olds. Following combined alpha- and beta-adrenergic receptor blockade, infusion of 20 micrograms/kg/min DPA inhibited renal vasoconstriction in most animals and elicited mesenteric vasodilation in all. The results indicate that dopaminergic responses undergo a postnatal maturation which has a different time course for different regional circulations.