Context, complexity and process in the implementation of evidence-based innovation: a realist informed review.

BACKGROUND: This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process. METHODS: Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers' Diffusion of Innovations theory (DOI) and Harvey and Kitson's integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors. RESULTS: A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries. CONCLUSIONS: The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience.

PURPOSE: Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation. MATERIALS AND METHODS: Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days. RESULTS: The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses. CONCLUSION: Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

Resource use and health outcomes of paediatric extracorporeal membrane oxygenation.

The use of extracorporeal membrane oxygenation can be rationalised by the assumption that non-zero survival after refractory cardiorespiratory failure represents improved outcome. Survivors may have cognitive and or functional morbidities, require complex ongoing care, and as a consequence consume considerable healthcare resources.

Tension pneumothorax secondary to grass head aspiration.

Aspiration of inflorescence or grass heads (seed head of grasses) often presents with atypical signs and symptoms because grass heads have a tendency to rapidly migrate to the periphery of the lung. If this is not recognized, it can lead to delay in diagnosis and serious complications. Removal with rigid bronchoscopy maybe difficult, and surgery is often needed. We report a case of a seven-month-old child who had a delayed diagnosis of grass head aspiration and subsequently presented with a life threatening tension pneumothorax. This case highlights the importance of obtaining a detailed history in cases of foreign body aspiration and the need to include it in the differential diagnosis of unexplained respiratory symptoms, especially those of sudden onset in children.