Digital Health Implementation Strategies Coproduced With Adults With Acquired Brain Injury, Their Close Others, and Clinicians: Mixed Methods Study With Collaborative Autoethnography and Network Analysis.

BACKGROUND: Acquired brain injuries (ABIs), such as stroke and traumatic brain injury, commonly cause cognitive-communication disorders, in which underlying cognitive difficulties also impair communication. As communication is an exchange with others, close others such as family and friends also experience the impact of cognitive-communication impairment. It is therefore an internationally recommended best practice for speech-language pathologists to provide communication support to both people with ABI and the people who communicate with them. Current research also identifies a need for neurorehabilitation professionals to support digital communication, such as social media use, after ABI. However, with >135 million people worldwide affected by ABI, alternate and supplementary service delivery models are needed to meet these communication needs. The "Social Brain Toolkit" is a novel suite of 3 interventions to deliver communication rehabilitation via the internet. However, digital health implementation is complex, and minimal guidance exists for ABI. OBJECTIVE: This study aimed to support the implementation of the Social Brain Toolkit by coproducing implementation knowledge with people with ABI, people who communicate with people with ABI, clinicians, and leaders in digital health implementation. METHODS: A maximum variation sample (N=35) of individuals with living experience of ABI, close others, clinicians, and digital health implementation leaders participated in an explanatory sequential mixed methods design. Stakeholders quantitatively prioritized 4 of the 7 theoretical domains of the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as being the most important for Social Brain Toolkit implementation. Qualitative interview and focus group data collection focused on these 4 domains. Data were deductively analyzed against the NASSS framework with stakeholder coauthors to determine implementation considerations and strategies. A collaborative autoethnography of the research was conducted. Interrelationships between considerations and strategies were identified through a post hoc network analysis. RESULTS: Across the 4 prioritized domains of "condition," "technology," "value proposition," and "adopters," 48 digital health implementation considerations and 52 tailored developer and clinician implementation strategies were generated. Benefits and challenges of coproduction were identified. The post hoc network analysis revealed 172 unique relationships between the identified implementation considerations and strategies, with user and persona testing and responsive design identified as the potentially most impactful strategies. CONCLUSIONS: People with ABI, close others, clinicians, and digital health leaders coproduced new knowledge of digital health implementation considerations for adults with ABI and the people who communicate with them, as well as tailored implementation strategies. Complexity-informed network analyses offered a data-driven method to identify the 2 most potentially impactful strategies. Although the study was limited by a focus on 4 NASSS domains and the underrepresentation of certain demographics, the wealth of actionable implementation knowledge produced supports future coproduction of implementation research with mutually beneficial outcomes for stakeholders and researchers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/35080.

Implementation of Web-Based Psychosocial Interventions for Adults With Acquired Brain Injury and Their Caregivers: Systematic Review.

BACKGROUND: More than 135 million people worldwide live with acquired brain injury (ABI) and its many psychosocial sequelae. This growing global burden necessitates scalable rehabilitation services. Despite demonstrated potential to increase the accessibility and scalability of psychosocial supports, digital health interventions are challenging to implement and sustain. The Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework can offer developers and researchers a comprehensive overview of considerations to implement, scale, and sustain digital health interventions. OBJECTIVE: This systematic review identified published, peer-reviewed primary evidence of implementation outcomes, strategies, and factors for web-based psychosocial interventions targeting either adults with ABI or their formal or informal caregivers; evaluated and summarized this evidence; synthesized qualitative and quantitative implementation data according to the NASSS framework; and provided recommendations for future implementation. Results were compared with 3 hypotheses which state that complexity (dynamic, unpredictable, and poorly characterized factors) in most or all NASSS domains increases likelihood of implementation failure; success is achievable, but difficult with many complicated domains (containing multiple interacting factors); and simplicity (straightforward, predictable, and few factors) in most or all domains increases the likelihood of success. METHODS: From a comprehensive search of MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, speechBITE, and neuroBITE, we reviewed primary implementation evidence from January 2008 to June 2020. For web-based psychosocial interventions delivered via standard desktop computer, mobile phone, tablet, television, and virtual reality devices to adults with ABI or their formal or informal caregivers, we extracted intervention characteristics, stakeholder involvement, implementation scope and outcomes, study design and quality, and implementation data. Implementation data were both narratively synthesized and descriptively quantified across all 7 domains (condition, technology, value proposition, adopters, organization, wider system, and their interaction over time) and all subdomains of the NASSS framework. Study quality and risk of bias were assessed using the 2018 Mixed Methods Appraisal Tool. RESULTS: We identified 60 peer-reviewed studies from 12 countries, including 5723 adults with ABI, 1920 carers, and 50 health care staff. The findings aligned with all 3 hypotheses. CONCLUSIONS: Although studies were of low methodological quality and insufficient number to statistically test relationships, the results appeared consistent with recommendations to reduce complexity as much as possible to facilitate implementation. Although studies excluded individuals with a range of comorbidities and sociocultural challenges, such simplification of NASSS domain 1 may have been necessary to advance intervention value propositions (domain 3). However, to create equitable digital health solutions that can be successfully implemented in real-world settings, it is recommended that developers involve people with ABI, their close others, and health care staff in addressing complexities in domains 2 to 7 from the earliest intervention design stages. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020186387; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186387. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1177/20552076211035988.

'It gives you encouragement because you're not alone': A pilot study of a multi-component social media skills intervention for people with acquired brain injury.

BACKGROUND: People with an acquired brain injury (ABI) find it challenging to use social media due to changes in their cognition and communication skills. Using social media can provide opportunities for positive connection, but there is a lack of interventions specifically designed to support safe and successful social media use after ABI. AIMS: To investigate the outcomes of completing a social media skills intervention and identify barriers and facilitators for future implementation. METHODS & PROCEDURES: The study used a mixed-methods, pre-post-intervention design. A total of 17 adults with an ABI were recruited. Participants completed an intervention that included a short self-guided course about social media skills (social-ABI-lity course), and then participated in a private, moderated Facebook group over a 12-week period (social-ABI-lity Facebook group). Data were collected over this period through observation of group activity and weekly surveys. They were also collected on social media use and quality of life at pre-intervention, post-intervention and after 3 months. Participants provided feedback on the experience of participating in the programme via a post-intervention interview. OUTCOMES & RESULTS: At post-intervention, there were significant improvements in confidence in using Facebook (p = 0.002) and enjoyment of using Facebook to connect with others (p = 0.013). There was no significant change in reported quality of life, although participants described the multiple benefits of connection they perceived from involvement in the group. Observational data and feedback interviews were informative about the feasibility and acceptability of the intervention. CONCLUSIONS & IMPLICATIONS: This pilot study provided preliminary evidence that an intervention comprising a short, self-guided training course and a private, moderated Facebook group improved outcomes for people with ABI. Key recommendations for future implementation include embedding active peer moderators within groups and taking an individualized approach to delivery of the intervention. WHAT THIS PAPER ADDS: What is already known on the subject Research has documented the challenges that people with ABI experience in using social media, and the difficulty for rehabilitation clinicians in providing appropriate support in this field. What this paper adds to existing knowledge This pilot study reports the outcomes of people with ABI completing a short, self-guided social media skills course and participating in a private, moderated Facebook group. After the intervention, participants reported significantly increased confidence and enjoyment in using Facebook, described the benefits of connection found in the groups, and suggested potential improvements for future implementation. What are the potential or actual clinical implications of this work? With the growing use of social media for connection and participation, there is a professional obligation to address social media communication skills in cognitive-communication rehabilitation for people with ABI. The findings of this study will inform interventions and future research to assist people with ABI to build their social media skills for communication, social support and a sense of connection.

Managing Uncertainty During the Communication of Diagnostic Test Information Between Patients and Clinicians in Australian Emergency Care.

We sought (a) an inductive understanding of patient and clinician perspectives and experiences of the communication of diagnostic test information and (b) a normative understanding of the management of uncertainty that occurs during the clinical encounter in emergency care. Between 2016 and 2018, 58 interviews were conducted with patients and nursing, medical, and managerial staff. Interview data were sequentially analyzed through an inductive thematic analysis, then a normative theory of uncertainty management. Themes of "Ideals," "Service Efficiency," and "Managing Uncertainty" were inductively identified as influencing the communication of diagnostic test information. A normative theory of uncertainty management highlighted (a) how these themes reflected the interaction's sociocultural context, encapsulated various criteria by which clinicians and patients evaluated the appropriateness and effectiveness of their communication, and represented competing goals during the clinical encounter, and (b) how systemic tensions between themes accounted for when diagnostic test information communication occurred, was deferred or avoided.

Digital Health Interventions for Adults with Acquired Brain Injury and Their Close Others: Implementation, Scalability, and Sustainability in the COVID-19 Context.

The Social Brain Toolkit is a novel suite of web-based interventions to support people with acquired brain injury and their close others with communication difficulties post-injury. The aim of this study was to investigate potential impacts of the Toolkit's wider political, economic, regulatory, professional, and sociocultural context on its implementation, scalability, and sustainability. Nine people with academic, healthcare or industry experience implementing digital health interventions prior to and during COVID-19 were individually interviewed. Data were deductively analysed according to the Non-adoption, Abandonment, Scaleup, Spread and Sustainability framework, with a focus on the domain of the 'Wider system'. Results indicated that COVID-19 facilitated a pivot to virtual care models which was timely for the implementation of the Social Brain Toolkit; political and economic changes were entwined; and risk management, data compliance and governance were key considerations for healthcare professionals and organisations.

Developing Social-ABI-lity: An Online Course to Support Safe Use of Social Media for Connection After Acquired Brain Injury.

PURPOSE: People who have an acquired brain injury (ABI) experience challenges using social media. Inversely, rehabilitation clinicians report feeling inadequately prepared to support them in its use. We aimed to develop a collaboratively designed, evidence-based online training resource to support people with an ABI to learn about using social media. Key recommendations for course design have previously been identified through a mixed methods approach, including (a) qualitative exploration of the experiences of people who use social media after ABI, (b) a scoping review to identify key features and effective teaching approaches from existing social media skills training programs. METHOD: Further design recommendations were obtained in this mixed methods study through (c) collaborative design of course content and features with 23 people, including people with living experience of ABI and other key stakeholders, and (d) a pilot trial of the course prototype with four participants who had an ABI (two men, two women; aged 28-69 years). RESULTS: Training needs to be interactive, including practical components addressing online safety and wellbeing, and to explain how to use social media platforms to connect with others. The first social-ABI-lity prototype incorporated these findings. Pilot data indicated that the prototype was beneficial, with participants demonstrating small increases in social media confidence and knowledge. Areas for further refinement were also identified. CONCLUSION: The social-ABI-lity self-directed online course is the first of its kind to support people with an ABI in using social media and will be a valuable resource for rehabilitation clinicians internationally. This resource may drive sustainable changes in participation by helping people with ABI to build their social media mastery and to participate in supportive online networks.

Coproducing Knowledge of the Implementation of Complex Digital Health Interventions for Adults with Acquired Brain Injury and their Communication Partners: Protocol for a Mixed Methods Study.

BACKGROUND: The Social Brain Toolkit, conceived and developed in partnership with stakeholders, is a novel suite of web-based communication interventions for people with brain injury and their communication partners. To support effective implementation, the developers of the Social Brain Toolkit have collaborated with people with brain injury, communication partners, clinicians, and individuals with digital health implementation experience to coproduce new implementation knowledge. In recognition of the equal value of experiential and academic knowledge, both types of knowledge are included in this study protocol, with input from stakeholder coauthors. OBJECTIVE: This study aims to collaborate with stakeholders to prioritize theoretically based implementation targets for the Social Brain Toolkit, understand the nature of these priorities, and develop targeted implementation strategies to address these priorities, in order to support the Social Brain Toolkit's implementation. METHODS: Theoretically underpinned by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework of digital health implementation, a maximum variation sample (N=35) of stakeholders coproduced knowledge of the implementation of the Social Brain Toolkit. People with brain injury (n=10), communication partners (n=11), and clinicians (n=5) participated in an initial web-based prioritization survey based on the NASSS framework. Survey completion was facilitated by plain English explanations and accessible captioned videos developed through 3 rounds of piloting. A speech-language pathologist also assisted stakeholders with brain injury to participate in the survey via video teleconference. Participants subsequently elaborated on their identified priorities via 7 web-based focus groups, in which researchers and stakeholders exchanged stakeholder perspectives and research evidence from a concurrent systematic review. Stakeholders were supported to engage in focus groups through the use of visual supports and plain English explanations. Additionally, individuals with experience in digital health implementation (n=9) responded to the prioritization survey questions via individual interview. The results will be deductively analyzed in relation to the NASSS framework in a coauthorship process with people with brain injury, communication partners, and clinicians. RESULTS: Ethical approval was received from the University of Technology Sydney Health and Medical Research Ethics Committee (ETH20-5466) on December 15, 2020. Data were collected from April 13 to November 18, 2021. Data analysis is currently underway, with results expected for publication in mid-2022. CONCLUSIONS: In this study, researchers supported individuals with living experience of acquired brain injury, of communicating with or clinically supporting someone post injury, and of digital health implementation, to directly access and leverage the latest implementation research evidence and theory. With this support, stakeholders were able to prioritize implementation research targets, develop targeted implementation solutions, and coauthor and publish new implementation findings. The results will be used to optimize the implementation of 3 real-world, evidence-based interventions and thus improve the outcomes of people with brain injury and their communication partners. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35080.

Deep learning models for histologic grading of breast cancer and association with disease prognosis.

Histologic grading of breast cancer involves review and scoring of three well-established morphologic features: mitotic count, nuclear pleomorphism, and tubule formation. Taken together, these features form the basis of the Nottingham Grading System which is used to inform breast cancer characterization and prognosis. In this study, we develop deep learning models to perform histologic scoring of all three components using digitized hematoxylin and eosin-stained slides containing invasive breast carcinoma. We first evaluate model performance using pathologist-based reference standards for each component. To complement this typical approach to evaluation, we further evaluate the deep learning models via prognostic analyses. The individual component models perform at or above published benchmarks for algorithm-based grading approaches, achieving high concordance rates with pathologist grading. Further, prognostic performance using deep learning-based grading is on par with that of pathologists performing review of matched slides. By providing scores for each component feature, the deep-learning based approach also provides the potential to identify the grading components contributing most to prognostic value. This may enable optimized prognostic models, opportunities to improve access to consistent grading, and approaches to better understand the links between histologic features and clinical outcomes in breast cancer.

Implementation of online psychosocial interventions for people with neurological conditions and their caregivers: A systematic review protocol.

BACKGROUND: As the burden of neurological conditions increases globally, online psychosocial interventions offer a potentially scalable solution to enabling healthcare access. However, their successful development and implementation require research into electronic healthcare implementation specifically. METHODS: Using a search strategy combining the concepts of implementation, electronic healthcare, psychosocial interventions and neurological conditions, we will conduct comprehensive electronic searches for primary implementation evidence in MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, SpeechBITE and NeuroBITE databases. Included studies will be analysed according to the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework, appraised using the Mixed-Methods Appraisal Tool and evaluated for theoretical underpinning in implementation science, with hybrid studies of effectiveness-implementation research classified according to the type of hybrid design. DISCUSSION: This review will be the first to use a theoretical underpinning in the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework to evaluate strengths and gaps in existing implementation research into online psychosocial interventions for people with neurological conditions and/or their caregivers. The results may be useful to provide direction and recommendations for future clinical implementation and research into online psychosocial interventions for people with neurological conditions and/or their caregivers. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2020: CRD42020186387.

A Web-Based Service Delivery Model for Communication Training After Brain Injury: Protocol for a Mixed Methods, Prospective, Hybrid Type 2 Implementation-Effectiveness Study.

BACKGROUND: Acquired brain injuries (ABIs) commonly cause cognitive-communication disorders, which can have a pervasive psychosocial impact on a person's life. More than 135 million people worldwide currently live with ABI, and this large and growing burden is increasingly surpassing global rehabilitation service capacity. A web-based service delivery model may offer a scalable solution. The Social Brain Toolkit is an evidence-based suite of 3 web-based communication training interventions for people with ABI and their communication partners. Successful real-world delivery of web-based interventions such as the Social Brain Toolkit requires investigation of intervention implementation in addition to efficacy and effectiveness. OBJECTIVE: The aim of this study is to investigate the implementation and effectiveness of the Social Brain Toolkit as a web-based service delivery model. METHODS: This is a mixed methods, prospective, hybrid type 2 implementation-effectiveness study, theoretically underpinned by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework of digital health implementation. We will document implementation strategies preemptively deployed to support the launch of the Social Brain Toolkit interventions, as well as implementation strategies identified by end users through formative evaluation of the Social Brain Toolkit. We will prospectively observe implementation outcomes, selected on the basis of the NASSS framework, through quantitative web analytics of intervention use, qualitative and quantitative pre- and postintervention survey data from all users within a specified sample frame, and qualitative interviews with a subset of users of each intervention. Qualitative implementation data will be deductively analyzed against the NASSS framework. Quantitative implementation data will be analyzed descriptively. We will obtain effectiveness outcomes through web-based knowledge tests, custom user questionnaires, and formal clinical tools. Quantitative effectiveness outcomes will be analyzed through descriptive statistics and the Reliable Change Index, with repeated analysis of variance (pretraining, posttraining, and follow-up), to determine whether there is any significant improvement within this participant sample. RESULTS: Data collection commenced on July 2, 2021, and is expected to conclude on June 1, 2022, after a 6-month sample frame of analytics for each Social Brain Toolkit intervention. Data analysis will occur concurrently with data collection until mid-2022, with results expected for publication late 2022 and early 2023. CONCLUSIONS: End-user evaluation of the Social Brain Toolkit's implementation can guide intervention development and implementation to reach and meet community needs in a feasible, scalable, sustainable, and acceptable manner. End user feedback will be directly incorporated and addressed wherever possible in the next version of the Social Brain Toolkit. Learnings from these findings will benefit the implementation of this and future web-based psychosocial interventions for people with ABI and other populations. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12621001170819; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001170819, Australia and New Zealand Clinical Trials Registry ACTRN12621001177842; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001177842, Australia and New Zealand Clinical Trials Registry ACTRN12621001180808; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001180808. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31995.

Cepheid Xpert® Flu/RSV and Seegene Allplex™ RP1 show high diagnostic agreement for the detection of influenza A/B and respiratory syncytial viruses in clinical practice.

BACKGROUND: Molecular assays based on reverse transcription-polymerase chain reaction (RT-PCR) provide reliable results for the detection of respiratory pathogens, although diagnostic agreement varies. This study determined the agreement between the RT-PCR assays (Xpert® Flu/RSV vs Allplex™ RP1) in detecting influenza A, influenza B, and respiratory syncytial viruses (RSVs) in clinical practice. METHODS: We retrospectively identified 914 patient encounters where testing with both Xpert® Flu/RSV and Allplex™ RP1 was undertaken between October 2015 and September 2019 in seven hospitals across New South Wales, Australia. The diagnostic agreement of the two assays was evaluated using positive percent agreement, negative percent agreement, and prevalence and bias-adjusted kappa. RESULTS: The positive percent agreement was 95.1% for influenza A, 87.5% for influenza B, and 77.8% for RSV. The negative percent agreement was 99.4% for influenza A, 99.9% for influenza B, and 100% for RSV. The prevalence and bias-adjusted kappa was 0.98 for influenza A, 0.99 for influenza B, and 0.97 for RSV. In a sensitivity analysis, the positive percent agreement values were significantly higher during the non-influenza season than the influenza season for influenza B and RSV. CONCLUSIONS: The Xpert® Flu/RSV and Allplex™ RP1 demonstrated a high diagnostic agreement for all three viruses assessed. The seasonal variation in the positive percent agreement of the two assays for influenza B and RSV may have been due to lower numbers assessed, variability in the virology of infections outside the peak season, or changes in the physiology of the infected host in different seasons.

Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol.

INTRODUCTION: There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS: This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION: This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.

Evaluating the long-term effects of a data-driven approach to reduce variation in emergency department pathology investigations: study protocol for evaluation of the NSW Health Pathology Atlas of variation.

INTRODUCTION: Variation in test ordering is a major issue in Australia and globally with significant financial and clinical impacts. There is currently a lack of research identifying and remediating variation in the use of pathology tests in emergency departments (EDs). In 2019, NSW Health Pathology introduced the Pathology Atlas of Variation that uses a data-driven tool (the Atlas Analytical Model) to investigate test order variation across New South Wales (NSW) and engage with local health districts (LHDs) to reduce variation. The objectives of this study are to evaluate whether this data-driven approach is associated with: (1) a reduction in test order variation; (2) improvements in patient outcomes and (3) cost benefits, for the five most frequent ED presentations. METHODS AND ANALYSIS: This is a large multisite study including 45 major public hospitals across 15 LHDs in NSW, Australia. The Atlas Analytical Model is a data analytics and visualisation tool capable of providing analytical insights into variation in pathology investigations across NSW EDs, which will be used as feedback to inform LHDs efforts to reduce variation. Interrupted time series analyses using 2 years pre Atlas (2017-2018) and 2 years post Atlas (2021-2022) data will be conducted. Study data will be obtained by linking hospital and laboratory databases. Funnel plots will be used to identify EDs with outlying pathology test ordering practices. The outcome measures include changes in test ordering practices, ED length of stay, hospital admission and cost benefits (total pathology costs per ED encounter). ETHICS AND DISSEMINATION: The study has received ethical approval from the NSW Population and Health Service Research Ethics Committee (reference, 2019/ETH00184). The findings of the study will be published in peer-reviewed journals and disseminated via presentations at conferences. We will also engage directly with key stakeholders to disseminate the findings and to inform policies related to pathology testing in the ED.

Shared Decision-Making in Emergency Departments: Context Sensitivity Through Divergent Discourses.

Patient-centred care and the empowerment of patients through shared clinical decision-making is a key goal of healthcare systems internationally. The Emergency Department is one of the first opportunities for shared decision-making to occur, with information exchanged between patient and clinician, between clinical disciplines, across the continuum of care, and between clinicians and ancillary departments including radiology and pathology laboratories. The successful development and implementation of sustainable health information technology (HIT) to support shared decision-making in Emergency care requires an understanding of the factors affecting this context. From a purposive, maximum variation sample of clinicians and a convenience sample of patients across three metropolitan and regional Emergency Departments in Australia, we identified three divergent discourses from an in-depth qualitative exploration of issues around shared decision-making. This allowed us to identify unanticipated factors affecting patient-centred care to inform context-sensitive implementation of HIT in the Emergency Department.

At the grassroots of home and community-based aged care: strategies for successful consumer engagement.

OBJECTIVES: (1) To describe the processes used to plan and conduct a stakeholder forum in aged care as a means of informing future uptake of consumer participatory research. (2) To discuss how capturing and drawing on stakeholders' experiences of aged care can generate new research ideas and inform the delivery of more person-centred aged care services. KEY PRINCIPLES OF CONSUMER ENGAGEMENT: A stakeholder forum was conducted as part of Ageing Well, a 2-year project evaluating the value and impact of social participation and quality of life tools as part of routine community aged care assessments at a large Australian provider. The forum was codesigned with community aged care clients and care coordinators and aimed to coproduce implementation strategies with a targeted representation of stakeholders. The stakeholder forum was developed using five key principles of consumer engagement activities: purposeful, inclusive, timely, transparent and respectful. The forum fostered an environment of mutual respect and collective inquiry to encourage contributions from all participants. This article outlines practical guidance on using a consumer engagement framework and the lessons learnt. DISCUSSION: The stakeholder forum facilitated an understanding of consumers' needs and existing gaps in aged care services and the circumstances that can enable or hinder the delivery and implementation of these services. This collective information can guide future research and policy at institutional, regional and national committees that relate to aged care. TRIAL REGISTRATION NUMBER: ACTRN12617001212347.

Factors affecting speech pathologists' implementation of stroke management guidelines: a thematic analysis.

PURPOSE: Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be underutilised. There is limited research into the reasons for this, especially in speech pathology. This study provides the first in-depth, qualitative examination of the barriers and facilitators that speech pathologists perceive and experience when implementing guidelines. METHODS: A maximum variation sample of eight speech pathologists participated in a semi-structured interview concerning the implementation of the National Stroke Foundation's Clinical Guidelines for Stroke Management 2010. Interviews were transcribed, thematically analysed and member checked before overall themes were identified. RESULTS: Three main themes and ten subthemes were identified. The first main theme, making implementation explicit, reflected the necessity of accessing and understanding guideline recommendations, and focussing specifically on implementation in context. In the second theme, demand versus ability to change, the size of changes required was compared with available resources and collaboration. The final theme, Speech pathologist motivation to implement guidelines, demonstrated the influence of individual perception of the guidelines and personal commitment to improved practice. CONCLUSIONS: Factors affecting implementation are complex, and are not exclusively barriers or facilitators. Some potential implementation strategies are suggested. Further research is recommended. IMPLICATIONS FOR REHABILITATION: In most Western nations, stroke remains the single greatest cause of disability, including communication and swallowing disabilities. Although adherence to stroke clinical practice guidelines improves stroke patient outcomes, guidelines continue to be underutilised, and the reasons for this are not well understood. This is the first in-depth qualitative study identifying the complex barriers and facilitators to guideline implementation as experienced by speech pathologists in stroke care. Suggested implementation strategies include local monitoring of guideline implementation (e.g. team meetings, audits), increasing collaboration on implementation projects (e.g. managerial involvement, networking), and seeking speech pathologist input into guideline development.