Are clinicians using routinely collected data to drive practice improvement? A cross-sectional survey.

BACKGROUND: Clinical registry participation is a measure of healthcare quality. Limited knowledge exists on Australian hospitals' participation in clinical registries and whether this registry data informs quality improvement initiatives. OBJECTIVE: To identify participation in clinical registries, determine if registry data inform quality improvement initiatives, and identify registry participation enablers and clinicians' educational needs to improve use of registry data to drive practice change. METHODS: A self-administered survey was distributed to staff coordinating registries in seven hospitals in New South Wales, Australia. Eligible registries were international-, national- and state-based clinical, condition-/disease-specific and device/product registries. RESULTS: Response rate was 70% (97/139). Sixty-two (64%) respondents contributed data to 46 eligible registries. Registry reports were most often received by nurses (61%) and infrequently by hospital executives (8.4%). Less than half used registry data 'always' or 'often' to influence practice improvement (48%) and care pathways (49%). Protected time for data collection (87%) and benchmarking (79%) were 'very likely' or 'likely' to promote continued participation. Over half 'strongly agreed' or 'agreed' that clinical practice improvement training (79%) and evidence-practice gap identification (77%) would optimize use of registry data. CONCLUSIONS: Registry data are generally only visible to local speciality units and not routinely used to inform quality improvement. Centralized on-going registry funding, accessible and transparent integrated information systems combined with data informed improvement science education could be first steps to promote quality data-driven clinical improvement initiatives.

Effectiveness of a Theory- and Web-Based Adaptive Implementation Intervention on Nurses' and Nursing Students' Intentions to Provide Brief Counseling: Protocol for a Randomized Controlled Trial.

BACKGROUND: Brief counseling can motivate patients to initiate health behavior change. However, increasing the provision of brief counseling by nurses is difficult due to contextual and practitioner-level factors impeding nurses' motivation and intentions to provide brief counseling (eg, unfavorable attitude toward brief counseling, lack of perceived control linked to barriers). Theory-based implementation interventions could address these practitioner-level factors and support evidence-based practice in the context of brief counseling. Web-based, adaptive e-learning (electronic learning) programs are a novel type of implementation intervention that could address the limitations of current brief counseling training programs, such as accessibility and personalization. OBJECTIVE: This paper presents a study protocol for evaluating the effectiveness of the E_MOTIVA implementation intervention-a theory- and web-based adaptive e-learning program-to increase nurses' and nursing students' intentions to provide brief counseling for smoking, an unbalanced diet, and medication nonadherence. METHODS: A two-group, single-blind, randomized controlled trial will be conducted with nurses and nursing students enrolled in a Bachelor of Science in Nursing program in Quebec, Canada. Participants in the experimental group will be allocated to the E_MOTIVA intervention-a theory- and web-based adaptive e-learning program-while participants in the active control group will be allocated to the E_MOTIVB intervention, a knowledge- and web-based standardized e-learning program. The E_MOTIVA intervention was designed to influence the constructs of the Theory of Planned Behavior (eg, attitude, subjective norms, and perceived behavioral control) in the context of brief counseling. The Cognitive Load Index and User Engagement Scale will be used to assess participants' cognitive load and engagement related to e-learning. Participants will complete the Brief Counseling Nursing Practices Questionnaire-Abridged Version at baseline and follow-up. All study measures will be completed online. RESULTS: The study is ongoing. The results of the study will provide answers to the primary hypothesis (H1) that experimental group participants will demonstrate a greater change in the score of intentions to provide brief counseling between baseline (-T1) and follow-up (T4). Secondary hypotheses include greater improvements in scores of attitude (H2), subjective norms (H3), perceived control (H4), behavioral beliefs (H5), normative beliefs (H6), and control beliefs (H7) regarding brief counseling in the experimental group between baseline and follow-up. We also anticipate lower intrinsic and extrinsic cognitive loads (H8, H9), higher germane cognitive load (H10), and higher engagement (H11, H12) in the experimental group. CONCLUSIONS: This study will be among the first in evaluating a novel type of implementation intervention, a theory- and web-based adaptive e-learning program, in nurses and nursing students. This type of intervention has the potential to support evidence-based practice through accessible, personalized training in wide-ranging domains in nursing. TRIAL REGISTRATION: ISRCTN Registry ISRCTN32603572; http://www.isrctn.com/ISRCTN32603572. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18894.

A nurse-led, rheumatologist-assisted telemedicine intervention for dose escalation of urate-lowering therapy in gout.

AIMS: Urate-lowering therapy (ULT) is effective in gout, but suboptimal management with wide variability in dose escalation remains widespread. We protocolized dose escalation of ULT to improve gout management. The aim was to reduce time to achieve target serum urate (SU) <360 µmol/L. METHODS: Process improvement tools were used to identify underlying causes of prolonged time to target SU. We designed a nurse-led telemedicine intervention for dose escalation of ULT. Patients with gout with SU ≥360 µmol/L meeting indications for ULT at a single institution were recruited. Exclusion criteria were estimated glomerular filtration rate <30 mL/min, pregnancy, cognitive impairment and poor mobility. A nurse-led telemedicine clinic was set up to perform patient education, monitoring of adverse events and drug escalation. We partnered with primary healthcare centers for routine blood tests. RESULTS: From July 2016 to December 2017, 127 patients were recruited. Median time to target SU was 19.0 weeks (interquartile range [IQR] 11.0-31.0). Median dose of allopurinol was 300 mg/d (IQR 200-400) in normal renal function and lower in renal impairment. Median telemedicine calls required to achieve target SU was 2 (IQR 1-3). No patient was hospitalized for gout flares. Two patients had adverse drug reactions, one required cessation of allopurinol for rash with eosinophilia, the other had self-resolving ulcers and allopurinol was continued. Lower baseline SU and number of gout flares were associated with attainment of target SU. CONCLUSION: A nurse-led telemedicine for gout care is effective and safe. Our results affirm the utility of telemedicine in increasing access to care and lower healthcare utilization.

Nurses' perceptions of the sustainability of a standardised assessment for preventing complications in a ICU: a qualitative study.

Background: Quality improvement projects have been widely adopted to prevent complications in the ICU. Objective: This paper describes nurses' perceptions of implementation strategies and the potential sustainability of a practice change intervention to prevent complications in a Malaysian ICU. Design: A participatory action research using five focus group discussions were undertaken with 19 nurses in a single ICU in regional Malaysia. Focus group transcripts were analysed using thematic analysis. Results: The main themes derived from the interviews were: [1] Empowering staff to embrace evidence-based practices; [2] Staff knowledge, attitudes, and beliefs that impact on behaviour; and [3] management support and leadership are influential in staff behaviours (acceptance & perseverance of change process). Discussion: Resistance to change was recognized as a barrier to adopting evidence based recommendations. There is a need to improve nurses' knowledge, attitude and awareness of the importance of assessment for VAP, CRBSI and PIs in the ICU.

Improving red cell transfusion in the elective surgical setting: an improvement collaborative with evaluation.

BACKGROUND & OBJECTIVES: Significant research conducted in New South Wales (NSW) hospitals' indicated that about 30% of red cell transfusions in stable adult patients was inappropriate. Of the total Australian government blood product budget in 2009-2010 (i.e. $878·8 million dollars) was spent on fresh blood products and plasma collection. The Clinical Excellence Commission (CEC) launched a systematic intervention called Blood Watch (BW) aiming to reduce inappropriate red cell transfusions in all NSW hospitals. An evaluation of BW was undertaken to measure the effectiveness of the programme and to estimate the associated potential cost-saving. MATERIALS & METHODS: Through the deterministic linkage of the four population-based administrative databases, three outcome indicators and four process indicators were developed. The analyses were of five elective surgical groups as they were the focus of the interventions. Three-level logistic regression and three-level linear regression were used to explore the time trend of the study process and outcome indicators. Modelling of the possible avoided red cell transfusions was also undertaken using a quadratic regression technique. RESULTS: Overall, there was a 27·4% reduction of the blood usage after the introduction of the BW programme and the reductions were consistent across five elective surgical groups. Such a reduction was associated with annual cost-savings of over $8·5 million. CONCLUSIONS: The BW programme which was based on collaborative improvement methods and implemented at scale led to significant reduction of blood usage, consistently across five elective surgical groups and significant cost-saving.

Improving on-time start for iMRI neurosurgeries.

BACKGROUND: In the Singapore General Hospital, intraoperative MRI (iMRI) neurosurgery is a multi-disciplinary process that involves staff from multiple departments. However, a baseline analysis showed that only 10.5% of iMRI neurosurgeries start on time, resulting in unnecessary waste of resources. The project aimed to improve the percentage of on-time start iMRI neurosurgeries to 100% within nine months. MATERIALS AND METHODS: Clinical Practice Improvement methodology was used. The project involves four phases: Diagnostic, in which a baseline analysis is conducted; Intervention, in which problem areas are identified; Implementation, in which potential solutions are implemented; and sustaining, in which strategies to sustain gains are discussed. RESULTS: The percentage of on-time start cases gradually increased to 100% in eight months, and was sustained above 85% in the following five months. CONCLUSION: This project serves as a successful demonstration of how quality improvement can be effected in a complex, multidisciplinary workflow, which is the norm for many hospital procedures.

The impact of oxandrolone on length of stay following major burn injury: a clinical practice evaluation.

INTRODUCTION: The anabolic agent oxandrolone (OX) has been found to decrease length of stay (LOS) following 20-60% total body surface area (TBSA) burn injury. This study uses the Comprehensive Severity Index (CSI) to control for severity of illness and explores the relationship between OX and LOS in a more broadly selected sample of burn patients and a natural practice setting. METHODS: A practice-based evidence study was conducted at a single regional burn center. Maximum severity of illness (MCSIC) was measured using a burn-specific version of CSI. Data on 167 consecutive surviving patients with TBSA≥15% were analyzed using case-control matching for MCSIC, TBSA, and age. Thirty-eight patients received OX. RESULTS: Median patient age for the entire patient sample was 42.7 years. Using a 1:1 match based upon MCSIC, TBSA, then age, mean LOS for patients who received OX was 33.6 days, as opposed to 43.4 days for those who were not managed with OX (p=0.03). If patients were matched >1:1 for controls: cases, mean LOS was 40.9 days (controls) versus 31.6 days (cases). CONCLUSIONS: OX is associated with shorter LOS after controlling for MCSIC, TBSA, and age. Future comparative effectiveness studies should better define which patients derive the greatest benefits from receipt of OX during their recovery from major burn injury.