Developing a tool to measure enactment of complex quality improvement interventions in healthcare.

Quality improvement (QI) projects are common in healthcare settings and often involve interdisciplinary teams working together towards a common goal. Many interventions and programmes have been introduced through research to convey QI skills and knowledge to healthcare workers, however, a few studies have attempted to differentiate between what individuals 'learn' or 'know' versus their capacity to apply their learnings in complex healthcare settings. Understanding and differentiating between delivery, receipt, and enactment of QI skills and knowledge is important because while enactment alone does not guarantee desired QI outcomes, it might be reasonably assumed that 'better enactment' is likely to lead to better outcomes. This paper describes the development, application and validation of a tool to measure enactment of core QI skills and knowledge of a complex QI intervention in a healthcare setting. Based on the Institute for Healthcare Improvement's Model for Improvement, existing QI assessment tools, literature on enactment fidelity and our research protocols, 10 indicators related to core QI skills and knowledge were determined. Definitions and assessment criteria were tested and refined in five iterative cycles. Qualitative data from four QI teams in long-term care homes were used to test and validate the tool. The final measurement tool contains 10 QI indicators and a five-point scale. Inter-rater reliability ranged from good to excellent. Usability and acceptability among raters were considered high. This measurement tool assists in identifying strengths and weaknesses of a QI team and allows for targeted feedback on core QI components. The indicators developed in our tool and the approach to tool development may be useful in other health related contexts where similar data are collected.

Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions.

BACKGROUND: Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation. METHODS: Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis. RESULTS: Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system. CONCLUSIONS: Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

Transformation under pressure: Discovery of a novel crystalline form of anthelmintic drug Praziquantel using high-pressure supercritical carbon dioxide.

Supercritical carbon dioxide (CO2) has been used as a processing technique to control polymorphism of pharmaceuticals. However, there are fewer reports of novel polymorphs being discovered by supercritical CO2 processing. As supercritical crystallization methods gain attention for potential in pharmaceutical processing, they may become a critical screening tool for discovery of new polymorphs. In this work, a case study is presented for a novel crystalline form of the anthelmintic drug, Praziquantel, found through supercritical CO2 processing. The novel form of Praziquantel was characterized by chromatography, nuclear magnetic resonance and infrared spectroscopy, X-ray powder diffraction, thermal analysis, and scanning electron microscopy. Furthermore, the novel form exhibited 13-20% improved solubility compared to commercial Form A between pH 1.6 and 7.5 and was physically stable under stressed conditions (40 °C and 75% relative humidity) for 7.5 weeks. Overall, this work showed that supercritical CO2 processing is a valuable tool to screen for novel, and possibly viable polymorphs of pharmaceutical compounds with improved properties.

Role of Policy in Best-Practice Dissemination: Informal Professional Advice Networks in Canadian Long-Term Care.

This article examines provincial policy influence on long-term care (LTC) professionals' advice-seeking networks in Canada's Maritime provinces. The effects of facility ownership, geography, and region-specific political landscapes on LTC best-practice dissemination are examined. We used sociometric statistics and network sociograms, calculated from surveys with 169 senior leaders in LTC facilities, to identify advice-seeking network structures and to select 11 follow-up interview participants. Network structures were distinguished by density, sub-group number, opinion leader, and boundary spanner distribution. Network structure was affected by ownership model in Nova Scotia and Prince Edward Island, and by regional geography in New Brunswick. Political instability within each province's LTC system negatively affected network actors' capabilities to enact innovation. Moreover, provincial policy variations influence advice-seeking network structures, facilitating and constraining relationship development and networking. Consequently, local policy context is essential to informing dissemination strategy design or implementation.

Ternary Phase Diagram Development and Production of Niclosamide-Urea Co-Crystal by Spray Drying.

In this work, a ternary phase diagram was developed for a Niclosamide-urea co-crystal (NCS-UR) in isopropanol (IPA) using a combination of slurry and solvent addition methods. The ternary phase diagram showed that solubility of Niclosamide and urea differed by an order of magnitude in IPA, leading to an incongruently saturating system. Spray drying was explored as a method to generate NCS-UR. Co-crystals with small, uniform particle size were successfully prepared by spray drying from equimolar solutions with yield up to 73%. Co-crystals were phase pure by X-ray powder diffraction (XRPD) and differential scanning calorimetry (DSC) from all conditions explored. Somewhat similar particles were obtained at inlet temperature of 70 °C (mean size of 2.0 µm) compared to 85 °C (2.8-3.4 µm). Based on the TPD, isolating phase pure co-crystal through solution crystallization in IPA would require excess urea. However, spray drying did not require excess co-former. The in-vitro solubility of NCS-UR was compared to anhydrous NCS in biorelevant media. NCS-UR did not give improvement in solubility at 1 h or 24 h. Overall, this work showed that spray drying is a feasible process for preparing phase pure co-crystals for an incongruently saturating system and simultaneously generating micron size particles.

The role of motivation in the diffusion of innovations in Canada's long-term care sector: a qualitative study.

BACKGROUND: Long-term care facilities offer shelter and care for Canadian seniors; however, there are great variances in the quality of care that is provided to older adults across facilities. One factor that could contribute to this variation in quality is the diffusion and implementation of advice and innovations within this sector. This study sought to understand the motivations of identified opinion leaders within the Canadian long-term care sector to disseminate advice within their social networks. Research questions addressed specific drivers of motivation and the potential outcomes of having motivated opinion leaders present within interpersonal advice-seeking networks with respect to diffusion and implementation of innovations in the Canadian long-term care sector. METHODS: This secondary analysis study analyzed semi-structured qualitative interviews with opinion leaders (n = 13) and advice seekers of opinion leaders (n = 13) from a national, social network study, Advice Seeking Networks in Long Term Care (Cranley et al. 2019; Dearing et al. 2017). Constant comparison analysis was used and supported by a theoretical framework developed from diffusion of innovation theory and the COM-B framework. RESULTS: The motivations of opinion leaders in the Canadian long-term care sector were represented across seven themes: obligations of the position, value of education, systemness, relationships, supportiveness, passion, and caring nature. CONCLUSIONS: This research provides further evidence that opinion leaders in the long-term care sector are motivated individuals and that they are using this motivation as a driver to create change and improve care practices. As residents of the long-term care sector continue to increase in number and complexity, the presence of motivated opinion leaders represents a promising outlook for the future through achieving specific outcomes such as the diffusion and implementation of innovations, an increased sense of community within the network, and increased readiness for the future.

Sustainment, Sustainability, and Spread Study (SSaSSy): protocol for a study of factors that contribute to the sustainment, sustainability, and spread of practice changes introduced through an evidence-based quality-improvement intervention in Canadian nursing homes.

BACKGROUND: Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation "boosters", and a "no booster" condition, and (iii) to compare the relative costs and impacts of each booster condition. METHODS/DESIGN: SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation "boosters", and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019. DISCUSSION: This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.

Barriers and Enablers to Implementing the Children's Hospital Early Warning Score: A Pre- and Post-Implementation Qualitative Descriptive Study.

PURPOSE: The purpose of this study was to identify and compare barriers and enablers to the implementation of the Children's Hospital Early Warning Score (CHEWS) on a pediatric inpatient unit pre- and post-implementation. DESIGN AND METHODS: A qualitative descriptive design, guided by the Theoretical Domains Framework, was used to conduct semi-structured focus groups and individual interviews with nurses on a pediatric inpatient unit to identify barriers and enablers in the pre- and post- CHEWS implementation phases. Data were analyzed using a directed content analysis approach followed by inductive thematic analysis. RESULTS: Two pre-implementation focus groups (N = 15) and 8 post-implementation individual interviews with nurses were conducted. We identified pre- and post- CHEWS implementation barriers related to clinical decision making, interprofessional relationships, the unit context, and negative emotions, and enablers related to quality of care and patient safety. The identified barriers and enablers to implementation were categorized within 13 TDF domains. CONCLUSIONS: Our findings illustrate a range of barriers and enablers to CHEWS implementation during the pre- and post-implementation phases. Tailored strategies are needed to overcome barriers related to nurses' perceptions of CHEWS impeding clinical decision-making and interprofessional collaboration. By addressing the identified barriers, we can leverage nurses' motivations for using CHEWS to improve the quality of patient care and enhance patient safety. PRACTICE IMPLICATIONS: The barriers and enablers identified in this study can be used to select implementation strategies to support the use of early warning systems in pediatric nursing practice.

Barriers and Enablers to Implementing a High-Dependency Care Model in Pediatric Care: A Preimplementation Study.

BACKGROUND: As the level of acuity of pediatric hospital admissions continues to increase, additional pressure is being placed on hospital resources and the nursing workforce. LOCAL PROBLEM: Currently, there is no formalized approach to care for high-acuity patients on our pediatric inpatient unit. METHODS: We used a qualitative descriptive design, guided by the Theoretical Domains Framework and Capability, Opportunity, Motivation-Behaviour (COM-B) model, to conduct focus groups and interviews with clinicians and administrators to identify potential barriers and enablers to implementing a high-dependency care (HDC) model. An HDC model focuses on the relationship between adequate nursing staff resources and patient acuity to improve patient health outcomes. RESULTS: Participants identified the need for clear guidelines and supportive physical structures to facilitate HDC implementation. Anticipated benefits included enhanced nursing confidence and family-centered care. CONCLUSIONS: Study findings highlight multilevel factors to consider prior to implementing an HDC model on a pediatric inpatient unit.

Partnering with parents to advance child health research.

Although patient engagement in research is widely touted as an important foundation for improving the relevance and sustainability of research findings, there is little consensus on how to do it in practice. This article describes our research team's experiences working with and engaging parents throughout the entire research process to reach full partnership in the identification, management, and dissemination of research. Our report of these experiences includes lessons learned along the way regarding how healthcare and research organizations can better support researchers and patients to achieve successful partnerships.

A novel process for preparation of fatty acid oil mixture in solid form.

The present study describes a novel and scalable process for preparation of omega-3 and omega-6 fatty acids in solid form. The process involves multiple steps consisting of combining the oil with a metal base in alcohol to form a solution, followed by addition of reaction mixture to acetonitrile (anti-solvent) to form a slurry and further separating the solid through filtration. This process results in formation of a flowable solid with yield of 44-76% depending on the procedure employed. The fatty acid profile of the calcium and magnesium salts was stable after one year of storage in ambient conditions. The type of solvent and anti-solvent employed in such process has tremendous effect on the resulting solid texture, which could range from complete gum to a workable, filterable solid. It was also demonstrated that increasing the concentration of base in alcohol reduces the amount of residual acetonitrile in the solid.

Interaction of the C-terminal peptide of pulmonary surfactant protein B (SP-B) with a bicellar lipid mixture containing anionic lipid.

The hydrophobic lung surfactant SP-B is essential for respiration. SP-B promotes spreading and adsorption of surfactant at the alveolar air-water interface and may facilitate connections between the surface layer and underlying lamellar reservoirs of surfactant material. SP-B63-78 is a cationic and amphipathic helical peptide containing the C-terminal helix of SP-B. (2)H NMR has been used to examine the effect of SP-B63-78 on the phase behavior and dynamics of bicellar lipid dispersions containing the longer chain phospholipids DMPC-d 54 and DMPG and the shorter chain lipid DHPC mixed with a 3∶1∶1 molar ratio. Below the gel-to-liquid crystal phase transition temperature of the longer chain components, bicellar mixtures form small, rapidly reorienting disk-like particles with shorter chain lipid components predominantly found around the highly curved particle edges. With increasing temperature, the particles coalesce into larger magnetically-oriented structures and then into more extended lamellar phases. The susceptibility of bicellar particles to coalescence and large scale reorganization makes them an interesting platform in which to study peptide-induced interactions between lipid assemblies. SP-B63-78 is found to lower the temperature at which the orientable phase transforms to the more extended lamellar phase. The peptide also changes the spectrum of motions contributing to quadrupole echo decay in the lamellar phase. The way in which the peptide alters interactions between bilayered micelle structures may provide some insight into some aspects of the role of full-length SP-B in maintaining a functional surfactant layer in lungs.

Dependence of bicellar system phase behavior and dynamics on anionic lipid concentration.

Bicellar dispersions of chain perdeuterated 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC-d54) and 1,2-dihexanoyl-sn-glycero-3-phosphocholine (DHPC) were prepared with the molar fraction of DHPC held fixed at 20% and varying amounts of DMPC replaced by the anionic lipid 1,2-dimyristoyl-sn-glycero-3-phospho-(1'-rac-glycerol) (DMPG). (2)H NMR spectra were examined to assess the effect of added DMPG on mixture phase behavior and morphology. Quadrupole echo decay and quadrupole-Carr-Purcell-Mieboom-Gill echo train measurements provided information about slow motions contributing to echo decay in the high temperature phases. The spectra and quadrupole echo decay properties of DMPC-d54/DHPC (4:1) and DMPC-d54/DMPG/DHPC (3:1:1) were qualitatively similar. With increasing DMPG concentration, the transition between the magnetically orientable phase and the higher temperature phase became increasingly distinct, and the spectral shape and echo decay characteristics of the high temperature bicellar phase became increasingly similar to those of DMPC-d54 in the liquid crystalline phase. The observation that DMPG changes spectra in the orientable phase incrementally while increasing the distinction between the orientable and high temperature bicellar phases provides new insights into how DMPG influences bicellar mixture morphology.