Facilitation as a component of evidence implementation: a multinational perspective.

BACKGROUND: Facilitation is a key component of JBI's approach to evidence implementation along with context analysis and evaluation of process and outcomes. Although the role of facilitation is recognized as a critical component of evidence implementation, what constitutes effective facilitation is poorly understood. AIM: This article presents a descriptive exploration of facilitation as it occurs in evidence implementation initiatives conducted in various healthcare and geographical contexts. All projects used the JBI approach to evidence implementation. METHODS: To provide a multinational perspective on how facilitation was operationalized to promote positive changes in clinical practice and health outcomes, five case studies of evidence implementation projects are presented. RESULTS: The cases highlighted that facilitation is a multifaceted process that can be met through a variety of roles that address aspects of education and capacity building, partnerships, action planning, problem solving and evaluation. Facilitation in all cases appeared to be collaborative, with multiple 'players' within and outside of the health organization being involved in the process. Although there are similarities in activities, facilitation involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case. Numerous contextual factors influenced the success of the implementation initiative. CONCLUSION: The cases emphasized the complex nature of facilitation as a strategy for evidence implementation, indicating that contextual attributes and features define the range of knowledge, skills, and activities that should take place in order for facilitation to be effective. Although there appears to be some core components, tailoring and adaptation of the facilitation process (or roles) is required.

Reduction of aggressive and violent behavior toward behavioral health unit staff and other patients: a best practice implementation project.

OBJECTIVES: The current project aimed to implement evidence-based recommendations for the management of inpatient aggressive and violent behaviors in four behavioral health units (BHUs) in a mental healthcare area within an academic medical center. INTRODUCTION: Patient violence against healthcare workers is a global concern, particularly in mental health care. All employees who work in inpatient psychiatric environments are at higher risk for targeted violence than are other healthcare workers. For healthcare organizations and staff, violent episodes involving patients can bring about medical expenses, potential legal expenditure, sick leave and a high turnover rate. The hospital at which this project was implemented had been experiencing a steady increase in violence and aggressive behavior. METHODS: The project used the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting practice change in four BHUs. A baseline retrospective audit of 10 electronic health records from four BHUs assessed compliance with best practice regarding violent episodes. The Getting Research into Practice tool was used to identify barriers and develop an evidence-based educational strategy for 70 BHU staff aimed to improve compliance with best practice for managing aggression and violence. Staff education compliance was assessed via hospital education department records. A pre and postimplementation staff satisfaction survey assessed perceptions about education, confidence and unit safety. RESULTS: The baseline audit indicated that one of the three criteria had 0% compliance. Following implementation of an educational strategy using mock codes for BHU staff, there was 96% improvement in compliance for the BHU staff education audit criterion. Staff de-escalated patients in 83% of the episodes postimplementation. There was a slight decrease (9.1%) in the rate of violence across all four inpatient BHUs. Staff satisfaction survey findings did not show a statistically significant difference. CONCLUSION: Enhanced evidence-based education and mock codes resulted in BHU staff competence and confidence in managing aggressive and/or violent patients. Early signs of a decrease in the violence rate and improvement in the efficient use of de-escalation will be sustained with on-going yearly education, quarterly mock codes and future audits. This project was limited by its small size and short timeframe (21 weeks), making results not generalizable.

Sugammadex versus neostigmine for postoperative nausea and vomiting in adult patients undergoing laparoscopic surgery paralyzed with rocuronium bromide: a systematic review protocol.

OBJECTIVES: The objective of this review is to determine if the occurrence of post-operative nausea and vomiting (PONV) is affected by using sugammadex or neostigmine, in adult patients undergoing laparoscopic procedures paralyzed by rocuronium bromide. INTRODUCTION: Laparoscopic procedures significantly increase the occurrence of PONV in patients. The focus should be on preventing the occurrence of PONV. Laparoscopic procedures use neo-muscular blocking agents to assist with creation of a pneumoperitoneum. After the procedure is complete, reversal of these agents is critical for patient recovery. Understanding the effects for each of the reversal medications is important for future decisions for peri-operative care. INCLUSION CRITERIA: This review will consider studies with patients aged 18 and older, undergoing laparoscopic procedures, paralyzed with rocuronium. METHODS: A search for relevant published and unpublished literature will be conducted in MEDLINE, CINAHL, Embase, Scopus, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials (CENTRAL), in addition to gray literature sources. Articles that meet the inclusion criteria will be further assessed for methodological validity by two independent reviewers using standardized critical appraisal instruments. Data will be extracted from papers included in the review using a standardized data extraction tool. Quantitative data will be pooled for statistical meta-analysis to evaluate the occurrence of PONV with both sugammadex and neostigmine.

Effectiveness of sugammadex versus neostigmine on restoration of neuromuscular function in surgical patients with myasthenia gravis undergoing rocuronium-induced neuromuscular blockade: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to identify the effectiveness of sugammadex versus neostigmine on the reversal of rocuronium-induced neuromuscular blockade in surgical patients with myasthenia gravis undergoing general anesthesia.

Beyond the Intensive Care Unit: Posttraumatic Stress Disorder in Critically Ill Patients.

Medical care progress has enabled more patients in the intensive care unit to survive critical illnesses and return to daily living. This shift in survival rates has shed new light on the emotional consequences this experience. For patients surviving an ICU stay, posttraumatic stress disorder has been identified in approximately 9% to 27% compared with 7% of the general US population. Practitioners have an important role to play in early identification of patients experiencing signs and symptoms of this disorder. Timely interventions and treatment may reduce the incidence of physical and psychological comorbid conditions.

Emerging Adjunctive Approach for the Treatment of Sepsis: Vitamin C and Thiamine.

Evidence is emerging that parenteral administration of high-dose vitamin C and thiamine may be a beneficial adjuvant therapy of severe sepsis and septic shock. Despite modern practices in critical care medicine, sepsis and severe sepsis remain a leading cause of morbidity and mortality in the critical care unit.

Effectiveness of preoperative intranasal dexmedetomidine, compared with oral midazolam, for the prevention of emergence delirium in the pediatric patient undergoing general anesthesia: a systematic review.

BACKGROUND: Emergence delirium is defined as a cognitive disturbance during emergence from general anesthesia resulting in hallucinations, delusions and confusion manifested by agitation, restlessness, involuntary physical movement and extreme flailing in bed. Postoperative emergence delirium develops in 12% to 18% of all children undergoing general anesthesia for surgery. This post-anesthetic phenomenon changes cognitive and psychomotor behavior, and puts pediatric patients and health care personnel at risk of injury. A newer drug, dexmedetomidine, is a selective alpha-2 agonist, which works in the brain and spinal cord that has sedative, analgesic and anxiolytic properties. Dexmedetomidine also has the ability to lower the overall anesthetic requirements by reducing sympathetic outflow in response to painful surgical stimulation. In current literature, there is not a systematic review that compares the effectiveness of preoperative intranasal dexmedetomidine administration against oral midazolam for the prevention of emergence delirium. OBJECTIVES: The objective of this review was to identify the effectiveness of preoperative intranasal dexmedetomidine compared to oral midazolam for the prevention of emergence delirium in the pediatric patient undergoing general anesthesia. INCLUSION CRITERIA TYPES OF PARTICIPANTS: This review considered studies that included pediatric patients aged three to seven years, with an American Society of Anesthesiologists (ASA) classification of I or II, and undergoing general anesthesia for elective/ambulatory surgery. This review excluded studies that included patients who had special needs including: developmental delay, chronic pain issues, and/or any preexisting mental or physical health disorders which categorized them above an ASA II. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: This review considered studies that compared preoperative intranasal administration of dexmedetomidine with preoperative oral administration of midazolam for the prevention of emergence delirium. TYPES OF STUDIES: This review considered both experimental and non-experimental study designs including randomized-controlled trials (RCTs), non-randomized control trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical cross-sectional studies for inclusion. OUTCOMES: This review considered studies that included the presence of postoperative emergence delirium. Only studies that used the Pediatric Anesthesia Emergence Delirium Scale to quantify the degree of emergence delirium were included in the review. Adverse events other than emergence delirium were not considered as part of the outcomes inclusion criteria but were to be included in the discussion if any articles were identified. SEARCH STRATEGY: The search strategy aimed to discover both published as well as unpublished studies. A three-step search strategy was utilized in eight databases. Studies published in English or with an English translation after 1999 were considered for inclusion in this review. METHODOLOGICAL QUALITY: Assessment of methodological quality was not conducted as no studies were identified which met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS: Data extraction and synthesis was not performed since no studies were included in this systematic review. RESULTS: Following the three-step search strategy as previously described, 117 articles were identified: six in Clinical Trials, one in ProQuest, 14 in Ovid MEDLINE, 10 in CINAHL, 16 in the Cochrane Library, 13 in Scopus, 36 in Embase, and 21 in Web of Science. There were 43 duplicates which were identified and removed in Refworks by the primary reviewer. The primary and secondary reviewers independently retrieved 10 potentially relevant studies (from the initial 74) through title and abstract screening as described in the inclusion criteria. All of the retrieved studies were excluded, after assessment of full text, with reasons based on the inclusion criteria. CONCLUSIONS: There is no scientific evidence identifying the effectiveness of preoperative intranasal dexmedetomidine, compared with oral midazolam, for the prevention of emergence delirium in the pediatric patient population.

Interpreting Laboratory Tests in Infection: Making Sense of Biomarkers in Sepsis and Systemic Inflammatory Response Syndrome for Intensive Care Unit Patients.

Sepsis and severe sepsis are leading causes of death in the United States and the most common causes of death among critically ill patients in noncoronary intensive care units. Diagnosis of infection and sepsis is a subjective clinical judgment based on the criteria for systemic inflammatory reaction, which is highly sensitive, not specific, and often misleading in intensively treated patients. Biomarkers are emerging as adjuncts to traditional diagnostic measures. No biomarkers have sufficient specificity or sensitivity to be routinely used in clinical practice, but they can aid in the diagnosis and treatment of infection versus inflammation.

Effectiveness of topical lidocaine as an adjuvant to propofol for procedural sedation in patients undergoing esophagogastroduodenoscopy procedures: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The quantitative objective is to identify the effectiveness of topical lidocaine as an adjuvant to propofol versus propofol alone for procedural sedation in adult patients undergoing esophagogastroduodenoscopy procedures.

Effectiveness of preoperative intranasal dexmedetomidine compared with oral midazolam for the prevention of emergence delirium in pediatric patients undergoing general anesthesia: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: This review aims to identify the effectiveness of preoperative intranasal dexmedetomidine compared with oral midazolam for the prevention of emergence delirium in pediatric patients undergoing general anesthesia.

The incidence of thromboembolism formation following the use of recombinant factor VIIa in patients suffering from blunt force trauma compared with penetrating trauma: a systematic review.

BACKGROUND: Rapid replacement of blood loss is critical in patients suffering from traumatic hemorrhage. When the availability of blood products is limited, certain interventions have shown promise in conserving blood supplies. Recombinant factor (rF) VIIa has been administered, as an off-label use, to assist in controlling hemorrhage in trauma patients. Although rFVIIa has a tendency to remain localized to areas of vascular insult, there may be an increase in thromboembolism formation when patients suffer multiple sites of injury as seen in blunt force trauma. OBJECTIVES: This review aimed to synthesize the best available evidence regarding the incidence of thromboembolism formation after receiving rFVIIa as an adjunct to hemorrhage control measures (standard resuscitation efforts consisting of varying amounts of packed red blood cells [PRBCs], fresh frozen plasma [FFP], platelets and crystalloid solutions) in patients suffering from traumatic injuries (blunt force and penetrating trauma). INCLUSION CRITERIA TYPES OF PARTICIPANTS: Civilian and combat trauma patients who were 15 years and older suffering from blunt force and penetrating traumatic injuries. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: Use of rFVIIa as an adjunct to hemorrhage control measures (standard resuscitation efforts consisting of varying amounts of PRBCs, FFP, platelets and crystalloid solutions). TYPES OF STUDIES: This review considered both experimental and epidemiological study designs. TYPES OF OUTCOMES: Confirmed formation of thromboembolism (confirmation based on specific diagnostic tests such as ultrasound, ventilation-perfusion scan or angiography). SEARCH STRATEGY: The databases searched included CINAHL, Ovid MEDLINE, Web of Science, EMBASE and the Cochrane Control Register of Clinical Trials. Studies published after June 1986 were considered for inclusion in this review. Search for unpublished studies was performed. METHODOLOGICAL QUALITY: Studies selected for inclusion were critically appraised by two independent reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI). DATA EXTRACTION: Data was extracted from articles using standardized data extraction instruments from the JBI. DATA SYNTHESIS: Quantitative results were pooled in statistical meta-analysis using the Joanna Briggs software for meta-analysis. RESULTS: Two studies with a total of 831 participants were included. Both the studies were randomized, placebo-controlled, double-blind trials. No studies of combat trauma patients met the inclusion criteria for this review. A meta-analysis was performed. In blunt force trauma patients, the incidence of thromboembolism formation on administering rFVIIa revealed an overall relative risk of 1.17 with a 95% confidence interval (CI) from 0.77 to 1.79; results not statistically significant (P = 0.4594); large CI and imprecise estimate. In penetrating trauma patients, the incidence of thromboembolism formation on administering rFVIIa revealed an overall relative risk of 0.77 with a 95% CI from 0.27 to 2.20; results not statistically significant (P = 0.6242); very large CI and imprecise estimate. CONCLUSIONS: The estimates of the effects are imprecise, results are compatible with effects in opposite directions, increase or decrease of thromboembolism formation, and an increase of thromboembolism formation cannot be excluded. IMPLICATIONS FOR PRACTICE: When rFVIIa is administered to trauma patients, there does not appear to be an increased risk of thromboembolism formation favoring one type of injury over the other (blunt force versus penetrating trauma). Owing to large CIs and imprecise estimates, the overall risk of thromboembolism cannot be excluded. The use of rFVIIa does appear to decrease the overall need for blood products in trauma patients with no statistically significant improvement in survival rates. With the high cost of rFVIIa, its use is limited to those facilities that can afford it. In situations wherein blood supply is limited, rFVIIa could conserve limited supplies of blood products with no difference in thromboembolism risk between blunt force versus penetrating trauma, but the high cost will ultimately limit its use to facilities that can afford it. The use of rFVIIa in blunt force and penetrating trauma patients has a JBI Grade B Recommendation (Appendix I). IMPLICATIONS FOR RESEARCH: This review excluded patients receiving pharmacologic anticoagulation such as warfarin sodium or heparin. The actions of these drugs will most likely counteract the desired coagulation effect of rFVIIa. Many studies do not account for the effects of rFVIIa in trauma patients receiving pharmacologic anticoagulation and this could be a future area of research.

Effectiveness of ondansetron as an adjunct to lidocaine intravenous regional anesthesia on tourniquet pain and postoperative pain in patients undergoing elective hand surgery: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this quantitative systematic review is to determine the effects of ondansetron as an adjunct to lidocaine on the tourniquet pain and postoperative pain of American Society of Anesthesiologists (ASA) class 1 or 2 adult patients undergoing elective hand surgery with intravenous regional anesthesia. BACKGROUND: Both injury and deformity of the upper extremity can result in dysfunction to nerves, tendons and bones which can lead to disability and pain. Hand injuries and deformities encompass an area of upper extremity surgery, wherein isolation and accessibility to peripheral nerves allows for a wide range of anesthesia techniques. Common hand surgeries include carpal tunnel or trigger finger release, Dupuytren's contracture fasciectomy, tendon repair, and ganglion cyst removal. According to the extent of injury or deformity, a general anesthetic, regional anesthetic, monitored anesthetic care (MAC) or local anesthetic may be used for these hand surgeries. Depending on the injury or deformity, local anesthesia may not provide sufficient anesthesia, but a general anesthesia may not be completely warranted either. Typical elective hand surgeries performed under regional anesthesia and MAC may be the ideal anesthetic plan that balances adequate sedation and analgesia. Intravenous regional anesthesia (IVRA), commonly known as a bier block, is a safe and effective anesthetic and is typically utilized in uncomplicated hand or forearm surgeries lasting less than an hour. Intravenous regional anesthesia was first developed by August Bier in 1908 for anesthesia of the hand and forearm. It is a regional anesthetic technique that is easy to perform, with success rates up to 98%. Intravenous regional anesthesia is a simple, reliable and cost-effective anesthesia technique for short ambulatory hand surgery. The IVRA technique is ideal for American Society of Anesthesiologists (ASA) class 1 or 2 patients, which according to ASA classification, are individuals who are healthy with well controlled to no comorbidities.The IVRA technique consists of inserting an intravenous catheter into a peripheral vein of the affected extremity. A double pneumatic tourniquet is applied to the same arm. The extremity is lifted and exsanguinated from distal to proximal with an Esmarch bandage. The proximal cuff of the tourniquet is then inflated to the appropriate pressure; standard 250mmHg for an upper extremity followed by the distal cuff. Insufflation times are limited to a maximum of one and a half to two hours, whereas the total insufflation time should never be less than 20 minutes. The Esmarch bandage is removed, and the local anesthetic is injected via the intravenous catheter to promote anesthesia in the operative area. In addition to the advantages of IVRA, there are disadvantages as well. These disadvantages include, but are not limited to, local anesthetic (LA) toxicity, delayed onset of action, poor muscle relaxation, tourniquet pain, and minimal postoperative analgesia. A method for improving analgesia and IVRA is to add medications to the IVRA solution. The ideal IVRA should include rapid onset of sensory and motor block, reduced LA dose, reduced intraoperative and tourniquet pain, prolonged postoperative analgesia, and minimal side effects.Adjuncts to LA can help offset some of the disadvantages mentioned above. In a systematic review of adjuncts for intravenous regional anesthesia conducted by Choyce and Peng, 29 studies were systematically reviewed to include various adjuncts to LA in IVRA. Adjuncts studied in this review included opioids, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs), clonidine, muscle relaxants, sodium bicarbonate and potassium. The results of this systematic review suggest that NSAIDs have the most potential to offer as adjuncts to IVRA, while opioid adjuncts to IVRA proved to be disappointing as a form of postoperative analgesia. The search for the optimal IVRA adjunct that improves analgesia but has limited side effects is ongoing. More recent studies on adjuncts to IVRA have included medications such as neostigmine, dexmetomidine, nitroglycerin, and ondansetron.Ondansetron is a specific 5-hydroxytryptamine-3 (5-HT3 or serotonin) antagonist, commonly used as an antiemetic drug for prevention or treatment of postoperative nausea and vomiting. Used in the recommended dose range, there are minimal reported side effects, with constipation, dizziness and headache being the most common. 5-HT3 antagonists such as ondansetron possess anti-inflammatory, anesthetic, and analgesic properties which may have a potential role in decreasing pain. 5-HT3 antagonists participate in the pathway of nociception by interfering with peripheral effects of serotonin on nociception. By binding to opioid mu receptors and acting as a potential opioid agonist, the result is a peripheral nociceptive analgesic effect. A study by Deegan shows that there are 5-HT3 receptors on the central spinal terminal, which suggests that ondansetron could have both peripheral and central nociceptive effects. Ambesh et al. found that pain during injection of propofol can be successfully prevented by the administration of 4 mg of ondansetron. In a study performed by Reddy et al., it was shown that 4 mg of ondansetron could significantly reduce pain during the intravenous (IV) injection of rocuronium and propofol.Ondansetron may be useful for its potential anti-in-ammatory effect as an adjunct to medication to reduce acute inflammation. Ondansetron can block sodium channels similar to local anesthetics and produce a local anesthetic effect. It has been shown to be approximately fifteen times more potent than lidocaine. A study by Farouk suggests the addition of ondansetron to lidocaine may improve the quality of IVRA and prolong postoperative analgesia in patients undergoing hand surgery. A study conducted by Honarmand, concluded that the addition of ondansetron to lidocaine for IVRA reduced intraoperative and postoperative analgesic use.Tourniquet pain, which is described as a dull and aching pain sensation, is caused by the nerve compression from the tourniquet. Neuropathic pain produced by nerve compression plays an important role in the etiology of this discomfort. Tourniquet pain is thought to be mediated by impulse propagation via small, unmyelinated, slow-conducting C fibers. The duration of the tourniquet time is directly proportional to the onset of tourniquet pain. In a study by Asik, onset of tourniquet pain ranged from eight to fifteen minutes. Tourniquet pain is a well-known limitation of IVRA and is a factor that can limit the number of times which IVRA can be used for extremity surgery. Lidocaine is one of the most frequently used LAs for IVRA. It has a relatively brief duration of action which may limit the postoperative analgesia. Duration of postoperative analgesia, measured as time to first analgesic requirement ranged from 34 to 45 minutes (median) with LA alone.Outcome measures will include pain assessment for intraoperative tourniquet pain and postoperative pain measured by first analgesic requirement time (the time elapsed after tourniquet release to the first request by the patient for analgesic). Pain will be assessed with a visual analog scale (VAS) (0 = no pain and 10 = worst pain imaginable). A VAS score of more than three would indicate pain threshold has been exceeded.A preliminary search of the Joanna Briggs Database of Systematic Reviews and Implementation Reports, the Cochrane Library, CINAHL, PubMed and PROSPERO has revealed that there are currently no systematic reviews (either published or underway) on the topic of ondansetron as an adjunct to lidocaine intravenous regional anesthesia. Search terms included Zofran, ondansetron, intravenous regional anesthesia, and IVRA. Outcomes of this review will determine if ondansetron, admixed with lidocaine, has an effect on tourniquet pain, and secondly to determine if ondansetron, admixed with lidocaine, has an effect on the duration of postoperative analgesia.

A systematic review of the effectiveness of intravenous tranexamic acid administration in managing perioperative blood loss in patients undergoing spine surgery.

This systematic review aimed to identify the effectiveness of intravenous tranexamic acid (TXA) administration in managing perioperative blood loss in patients undergoing spine surgery. The study design was a systematic review and meta-analysis. Quantitative articles were pooled in a statistical meta-analysis using the Joanna Briggs Institute Meta-Analysis of Statistical Assessment and Review Instrument. Twelve studies totaling 934 participants carried out between 1960 and 2013 were included in the review. Intraoperative blood loss showed statistically significant (P < .0001) blood loss in the control group compared with that in the treatment group. Perioperative blood loss was approaching significance for blood loss in the control group with an overall P = .067. TXA helps reduce perioperative blood loss for patients undergoing spine surgery. TXA should be administered to patients undergoing spine surgery when significant blood loss is anticipated.