Project description:ObjectiveUnderstand perceived barriers to and facilitators of using clinical informatics applications for pharmacogenomic (PGx) implementation in resource-limited settings.Materials and methodsWe conducted a qualitative research study using a semi-structured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview questions assessed CFIR contextual determinants related to: electronic health record (EHR) infrastructure; clinical informatics personnel and resources; EHR integration of PGx test results; PGx clinical decision support (CDS) tools; institutional resources; and partner receptivity. Transcripts were coded and analyzed to identify themes.ResultsWe interviewed 24 clinical informaticists and executive leaders working in rural or underserved health care settings in Montana (n = 15) and Colorado (n = 9) and identified three major themes: (1) EHR infrastructure limitations, (2) insufficient supporting resources, and (3) unique contextual considerations for resource-limited settings. EHR infrastructure limitations included limited agency related to EHR build and interoperability concerns. Theme 1 highlighted challenges associated with integrating structured data into the EHR and inadequate vendor support. Theme 2 included limited familiarity with PGx across the care team, cost concerns, and allocation of non-financial resources. Theme 3 highlighted perceptions about the clinical utility of PGx within rural and underrepresented populations. Potential facilitators, such as being able to act nimbly, were found to coexist among the reported barriers.Discussion and conclusionOur results provide insight into the clinical informatics infrastructure in resource-limited settings and identify unique considerations for clinical informatics-facilitated PGx implementation. Future efforts in these settings should consider innovative partnerships and strategies to leverage facilitators and minimize barriers associated with integrating PGx CDS applications.

Project description:BackgroundMaternity and neonatal services are rapidly changing in Australia because of evolving needs of the community and patient population. Clinical practice guidelines focused on early interventions and prevention strategies can decrease risk for preventable negative health outcomes in this population. However, despite the existence of several clinical practice guidelines, their translation into practice remains problematic for healthcare services.AimTo identify barriers and enablers for the implementation and adoption of clinical practice guidelines in maternal and neonatal settings.MethodsA rapid review was conducted according to Cochrane and World Health Organization guidelines. Systematic reviews, qualitative, quantitative and mixed-methods studies related to clinical guidelines in maternal and neonatal settings published in English Language between 2010 and 2023 meeting study eligibility criteria were identified using PubMed, Cochrane CENTRAL, EMBASE, and CINAHL databases.FindingsForty-eight studies originating from 35 countries were reviewed, representing practice guidelines associated with maternal and neonatal care. Identified barriers and enablers aligned to five main themes related to the contextual level of impact: (i) healthcare system and systemic factors, (ii) patient and population, (iii) guidelines and standards, (iv) organisational capacity, and (v) health professional practice.Discussion and conclusionFindings from this review shed light on the challenges and opportunities associated with introducing clinical practice guidelines in maternal and neonatal care settings. Implementation of guidelines into practice is complex, with different factors affecting their adoption and their use within healthcare settings. Addressing the multifaceted challenges associated with the implementation of clinical practice guidelines in maternal and neonatal care demands a comprehensive and collaborative strategy. Successful adoption of guidelines requires the involvement of stakeholders at all levels, supported by ongoing evaluation, feedback, and dedication to evidence-based practices.

Project description:BackgroundWhile clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings.MethodsThis descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel.ResultsSeven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model.ConclusionsUsing a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change.Trial registrationClinicalTrials.gov, NCT01815710 .

Project description:BackgroundLow-to-middle income countries (LMICs) experience a high burden of disease from both non-communicable and communicable diseases. Addressing these public health concerns requires effective implementation strategies and localization of translation of knowledge into practice.AimTo identify and categorize barriers and strategies to evidence implementation in LMICs from published evidence implementation studies.MethodsA descriptive analysis of key characteristics of evidence implementation projects completed as part of a 6-month, multi-phase, intensive evidence-based clinical fellowship program, conducted in LMICs and published in the JBI Database of Systematic Reviews and Implementation Reports was undertaken. Barriers were identified and categorized to the Donabedian dimensions of care (structure, process, and outcome), and strategies were mapped to the Cochrane effective practice and organization of care taxonomy.ResultsA total of 60 implementation projects reporting 58 evidence-based clinical audit topics from LMICs were published between 2010 and 2018. The projects included diverse populations and were predominantly conducted in tertiary care settings. A total of 279 barriers to implementation were identified. The most frequently identified groupings of barriers were process-related and associated predominantly with staff knowledge. A total of 565 strategies were used across all projects, with every project incorporating more than one strategy to address barriers to implementation of evidence-based practice; most strategies were categorized as educational meetings for healthcare workers.Linking evidence to actionContext-specific strategies are required for successful evidence implementation in LMICs, and a number of common barriers can be addressed using locally available, low-cost resources. Education for healthcare workers in LMICs is an effective awareness-raising, workplace culture, and practice-transforming strategy for evidence implementation.

Project description:INTRODUCTION:The COVID-19 pandemic has altered the professional practice of all healthcare workers, including radiographers. In the pandemic, clinical practice of radiographers was centred mostly on chest imaging of COVID-19 patients and radiotherapy treatment care delivery to those with cancer. This study aimed to assess the radiographers' perspective on the impact of the pandemic on their wellbeing and imaging service delivery in Ghana. METHODS:A cross-sectional survey of practising radiographers in Ghana was conducted online from March 26th to May 6th, 2020. A previously validated questionnaire that sought information regarding demographics, general perspectives on personal and professional impact of the pandemic was used as the research instrument. Data obtained was analysed using Microsoft Excel® 2016. RESULTS:A response rate of 57.3% (134/234) was obtained. Of the respondents, 75.4% (n = 101) reported to have started experiencing high levels of workplace-related stress after the outbreak. Three-quarters (n = 98, 73.1%) of respondents reported limited access to any form of psychosocial support systems at work during the study period. Half (n = 67, 50%) of the respondents reported a decline in general workload during the study period while only a minority (n = 18, 13.4%) reported an increase in workload due to COVID-19 cases. CONCLUSION:This national survey indicated that majority of the workforce started experiencing coronavirus-specific workplace-related stress after the outbreak. Albeit speculative, low patient confidence and fear of contracting the COVID-19 infection on hospital attendance contributed to the decline in general workload during the study period. IMPLICATIONS FOR PRACTICE:In order to mitigate the burden of workplace-related stress on frontline workers, including radiographers, and in keeping to standard practices for staff mental wellbeing and patient safety, institutional support structures are necessary in similar future pandemics.

Project description:BackgroundThe coronavirus disease-2019 (COVID-19) pandemic has again demonstrated the critical role of effective infection prevention and control (IPC) implementation to combat infectious disease threats. Standards such as the World Health Organization (WHO) IPC minimum requirements offer a basis, but robust evidence on effective IPC implementation strategies in low-resource settings remains limited. We aimed to qualitatively assess IPC implementation themes in these settings.MethodsSemi-structured interviews were conducted with IPC experts from low-resource settings, guided by a standardised questionnaire. Applying a qualitative inductive thematic analysis, IPC implementation examples from interview transcripts were coded, collated into sub-themes, grouped again into broad themes, and finally reviewed to ensure validity. Sub-themes appearing ≥ 3 times in data were highlighted as frequent IPC implementation themes and all findings were summarised descriptively.ResultsInterviews were conducted with IPC experts from 29 countries in six WHO regions. Frequent IPC implementation themes including the related critical actions to achieve the WHO IPC core components included: (1) To develop IPC programmes: continuous advocacy with leadership, initial external technical assistance, stepwise approach to build resources, use of catalysts, linkages with other programmes, role of national IPC associations and normative legal actions; (2) To develop guidelines: early planning for their operationalization, initial external technical assistance and local guideline adaption; (3) To establish training: attention to methods, fostering local leadership, and sustainable health system linkages such as developing an IPC career path; (4) To establish health care-associated (HAI) surveillance: feasible but high-impact pilots, multidisciplinary collaboration, mentorship, careful consideration of definitions and data quality, and "data for action"; (5) To implement multimodal strategies: clear communication to explain multimodal strategies, attention to certain elements, and feasible but high-impact pilots; (6) To develop monitoring, audit and feedback: feasible but high-impact pilots, attention to methods such as positive (not punitive) incentives and "data for action"; (7) To improve staffing and bed occupancy: participation of national actors to set standards and attention to methods such as use of data; and (8) To promote built environment: involvement of IPC professionals in facility construction, attention to multimodal strategy elements, and long-term advocacy.ConclusionsThese IPC implementation themes offer important qualitative evidence for IPC professionals to consider.

Project description:BackgroundWe evaluated a facilitation strategy to help clinical sites likely to experience challenges implement evidence-based Primary Care-Mental Health Integration (PC-MHI) care models within the context of a Department of Veterans Affairs (VA) initiative. This article describes our assessment of whether implementation facilitation (IF) can foster development of high quality PC-MHI programs that adhere to evidence, are sustainable and likely to improve clinical practices and outcomes.MethodsUtilizing a matched pair design, we conducted a qualitative descriptive evaluation of the IF strategy in sixteen VA primary care clinics. To assess program quality and adherence to evidence, we conducted one-hour structured telephone interviews, at two time points, with clinicians and leaders who knew the most about the clinics' programs. We then created structured summaries of the interviews that VA national PC-MHI experts utilized to rate the programs on four dimensions (overall quality, adherence to evidence, sustainability and level of improvement).ResultsAt first assessment, seven of eight IF sites and four of eight comparison sites had implemented a PC-MHI program. Our qualitative assessment suggested that experts rated IF sites' programs higher than comparison sites' programs with one exception. At final assessment, all eight IF but only five comparison sites had implemented a PC-MHI program. Again, experts rated IF sites' programs higher than their matched comparison sites with one exception. Over time, all ratings improved in five of seven IF sites and two of three comparison sites.ConclusionsImplementing complex evidence-based programs, particularly in settings that lack infrastructure, resources and support for such efforts, is challenging. Findings suggest that a blend of external expert and internal regional facilitation strategies that implementation scientists have developed and tested can improve PC-MHI program uptake, quality and adherence to evidence in primary care clinics with these challenges. However, not all sites showed these improvements. To be successful, facilitators likely need at least a moderate level of leaders' support, including provision of basic resources. Additionally, we found that IF and strength of leadership structure may have a synergistic effect on ability to implement higher quality and evidence-based programs.

Project description:ObjectiveTo gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries.DesignFocus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach.SettingCommunity, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care.ParticipantsHealthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors.ResultsWe conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability.ConclusionsPulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations.Trial registration numberNCT02941237.

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Barriers to implementation of evidence into clinical practice in low-resource settings.

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Barriers to implementation of evidence into clinical practice in low-resource settings.

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