Implementation Science

Implementation Science

Introduction

• This lecture aims to provide an understanding of implementation science and its application in healthcare.
• Key objectives include understanding implementation science, the Surgical Safety Checklist, processes in implementation, gaps in understanding, interventions, and research gaps.

Improvement Science

• Terms related to improvement science include:
  • Knowledge mobilization
  • Knowledge utilization
  • Quality improvement
  • Knowledge transfer
  • Knowledge translation

Implementation of Evidence

• Implementation of evidence results in behavior change, which can involve:
  • Replacing a behavior
  • Rejecting a behavior
  • Adopting a new behavior
  • Occurring at individual, group, or system levels

WHO Surgical Safety Checklist

• The WHO Surgical Safety Checklist, adapted for England and Wales, includes:
  • Sign In: Before anesthesia induction, verifying patient identity, site, procedure, consent, surgical site marking, anesthesia machine check, allergies, difficult airway/aspiration risk, and risk of significant blood loss (>500ml or 7ml/kg in children).
  • Time Out: Before surgical intervention, team members introduce themselves, and the surgeon, anesthetist, and nurse confirm patient name, procedure, site, position, anticipated blood loss, equipment requirements, specific concerns, ASA grade, monitoring equipment, sterility of instrumentation, equipment issues, SSI bundle, antibiotic prophylaxis, patient warming, hair removal, glycemic control, VTE prophylaxis, and essential imaging.
  • Sign Out: Before leaving the operating room, the registered practitioner confirms the procedure name, instrument/swab/sharp counts, specimen labeling, equipment problems, and key concerns for recovery.

Evidence-Based Medicine and the Surgical Safety Checklist

• A study by Haynes et al. (2009) in the New England Journal of Medicine (NEJM) demonstrated the impact of the Surgical Safety Checklist on reducing morbidity and mortality.

Outcomes Before and After Checklist Implementation

• Table 5 from the NEJM article presents outcomes before and after checklist implementation across multiple sites.
• Key metrics include surgical-site infection rates, unplanned returns to the operating room, pneumonia incidence, death rates, and overall complication rates.
• Significant reductions were observed in surgical-site infections, mortality, and overall complications after checklist implementation.

Specific Data Points

• Site 1: Surgical-Site Infection decreased from 4.0\% to 2.0\%, Unplanned Return to OR decreased from 4.6\% to 1.8\%, Death decreased from 1.0\% to 0.0\%, Any Complication decreased from 11.6\% to 7.0\%.
• Site 5: Surgical-Site Infection decreased dramatically from 20.5\% to 3.6\%, Any Complication decreased from 21.4\% to 5.5\%.
• Overall: Surgical-Site Infection decreased from 6.2\% to 3.4\%, Death decreased from 1.5\% to 0.8\%, Any Complication decreased from 11.0\% to 7.0\%.

Impact of the Checklist

• The rate of death decreased from 1.5\% before the checklist to 0.8\% after (P=0.003).
• Inpatient complications decreased from 11.0\% to 7.0\% (P<0.001).

Canadian Trial – NEJM 2014

• A Canadian trial published in NEJM in 2014 assessed the impact of the WHO Surgical Safety Checklist.
• Pre-checklist (n=109,341): 30-day mortality rate of 0.71\%, complication risk of 3.86\%.
• Post-checklist (n=106,370): 30-day mortality rate of 0.65\%, complication risk of 3.82\%.

Lack of Replication

• In some instances the results of implementing the checklist weren't replicated, which raises the following questions.
• Reasons for the lack of replication include different materials and protocols, different locations and contexts, and statistical regression to the mean.

Importance of Actual Use

• Dr. Lucian Leape (Harvard, NEJM 2014) suggested that the likely reason for the failure to replicate results was that the checklist was not consistently used.
• The behavior in the operating theatre didn't change.

Checklist as a Tool for Behavior Change

• A checklist on its own has no power; its effectiveness depends on the surgical team incorporating it into their practice, leading to behavior change.
• Behavior change can be a powerful force for good or ill.

Barriers and Facilitators of Implementation

• A study by Russ et al. (Ann Surg 2015) evaluated the barriers and facilitators of implementing the WHO Surgical Safety Checklist across hospitals in England.
• Implementation varied across hospitals, with some using preplanned/phased approaches.
• Staff sometimes felt the checklist was imposed, and there were issues with integrating it into pre-existing processes.
• The most common barrier was resistance from senior clinicians.

Determinants of Behavior

• Behavior is influenced by internal and external factors, including:
  • Knowledge
  • Skills
  • Social/professional role and identity
  • Beliefs about capabilities
  • Beliefs about consequences
  • Motivation and goals
  • Memory, attention, and decision processes
  • Environmental context and resources
  • Social influences
  • Emotion
  • Behavioral regulation
  • Nature of the behaviors

Behavior Change Techniques (BCTs)

• Susan Michie developed a taxonomy of behavior change techniques (93 at last count).
• This taxonomy serves as a reference point for selecting BCTs to achieve specific behavioral outcomes.
• Effective use of BCTs requires understanding the behavior change required and the behavior targeted for change.

Approaches to Changing Behavior in Healthcare

• Various approaches exist for changing behavior in healthcare, including:
  • Public health campaigns (media, health service, schools)
  • Legislation (seat belts, smoking, clean air, childhood immunizations)
  • Screening programs (cancer, early childhood)
  • Local commissioning of services (smoking, breastfeeding)
  • Education of healthcare staff (prevention programs)
  • Financial incentives (Quality and Outcomes Framework, Commission for Quality and Innovation)
  • Policing of services (Care Quality Commission)

Statins and Behavior Change Example

• Statins are drugs used to lower cholesterol and reduce the risk of arterial blockage recurrence.
• They should be prescribed in high doses of the cheapest form.
• Obstacles to changing statin prescription practices include various prescriber and system-level factors.

Potential Interventions:

• Educational programs for prescribers on statin use.
• National media campaigns to inform patients.
• Preventing the dispensing of more expensive statins without justification.
• Implementing a pop-up notification in the computer system.
• Blocking the prescription of expensive statins within the NHS.
• Conducting an experiment to determine the most cost-effective approach.

NICE and Implementation

• NICE (National Institute for Health and Care Excellence) is committed to implementing its guidance.
• They offer >1100 pieces of guidance on guideline implementation in local settings.
• Their approach is often common-sense, focusing on dissemination, audit, local service encouragement, and incentives.
• However, there is limited evidence on what works best in each circumstance.

'Do Not Do' Recommendations

• NICE makes 'do not do' recommendations, such as avoiding antipsychotics for ADHD treatment in adults.
• Routine blood tests and ECGs are generally not recommended for people taking methylphenidate, dexamfetamine, and atomoxetine unless clinically indicated.
• Drug treatment is not the first-line treatment for all school-age children with ADHD.

Cessation of Treatment

• An example is the cessation of combined inhalers in chronic obstructive pulmonary disease (COPD).
• In 2003, combination inhalers for COPD were introduced and became the most costly drugs in the NHS within three years.
• Most COPD patients took them, even though they were only indicated for a minority.
• Evidence published in 2013 showed it took six years for prescribing to fall (White P et al 2013 PLOS One. doi:10.1371/journal.pone.0075221).

Obstacles to Implementation

• Common obstacles to implementation include:
  • Lack of experience in executors
  • Inadequate planning
  • Disorganized work culture
  • Poor readiness to change
  • Poor team structure
  • Lack of necessary resources
  • Lack of leadership
  • Lack of commitment
  • Lack of prioritization

Key Issues in Implementation Science

1. Implementation of evidence-based practice is about behavior change.
2. To achieve change, the behavior should be understood.
3. Understanding the behavior leads to the best change techniques.
4. Evidence of benefit does not ensure implementation in practice.
5. Interventions to implement change in healthcare should be tested.

The Implementation of Evidence-Based Practice

• There is a significant financial investment in showing intervention efficacy/effectiveness.
• However, the implementation of an intervention in clinical practice is rarely tested!