Showing papers by "Russell L. Gruen published in 2015"

Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe Surgery and Anaesthesia

Abstract: Introduction The unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery.

Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department

Abstract: Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury in the emergency department (ED), variations in practice exist. Interventions designed to implement recommended behaviours can reduce this variation. Using theory to inform intervention development is advocated; however, there is no consensus on how to select or apply theory. Integrative theoretical frameworks, based on syntheses of theories and theoretical constructs relevant to implementation, have the potential to assist in the intervention development process. This paper describes the process of applying two theoretical frameworks to investigate the factors influencing recommended behaviours and the choice of behaviour change techniques and modes of delivery for an implementation intervention. A stepped approach was followed: (i) identification of locally applicable and actionable evidence-based recommendations as targets for change, (ii) selection and use of two theoretical frameworks for identifying barriers to and enablers of change (Theoretical Domains Framework and Model of Diffusion of Innovations in Service Organisations) and (iii) identification and operationalisation of intervention components (behaviour change techniques and modes of delivery) to address the barriers and enhance the enablers, informed by theory, evidence and feasibility/acceptability considerations. We illustrate this process in relation to one recommendation, prospective assessment of post-traumatic amnesia (PTA) by ED staff using a validated tool. Four recommendations for managing mild traumatic brain injury were targeted with the intervention. The intervention targeting the PTA recommendation consisted of 14 behaviour change techniques and addressed 6 theoretical domains and 5 organisational domains. The mode of delivery was informed by six Cochrane reviews. It was delivered via five intervention components : (i) local stakeholder meetings, (ii) identification of local opinion leader teams, (iii) a train-the-trainer workshop for appointed local opinion leaders, (iv) local training workshops for delivery by trained local opinion leaders and (v) provision of tools and materials to prompt recommended behaviours. Two theoretical frameworks were used in a complementary manner to inform intervention development in managing mild traumatic brain injury in the ED. The effectiveness and cost-effectiveness of the developed intervention is being evaluated in a cluster randomised trial, part of the Neurotrauma Evidence Translation (NET) program.

Wound Management in Disaster Settings

Abstract: Background Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management.

Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part II: Background to a research strategy

Abstract: Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part II: Background to a research strategy

Interventions for reducing wrong‐site surgery and invasive clinical procedures

Abstract: Background Specific clinical interventions are needed to reduce wrong-site surgery, which is a rare but potentially disastrous clinical error. Risk factors contributing to wrong-site surgery are variable and complex. The introduction of organisational and professional clinical strategies have a role in minimising wrong-site surgery. Objectives To evaluate the effectiveness of organisational and professional interventions for reducing wrong-site surgery (including wrong-side, wrong-procedure and wrong-patient surgery), including non-surgical invasive clinical procedures such as regional blocks, dermatological, obstetric and dental procedures and emergency surgical procedures not undertaken within the operating theatre. Search methods For this update, we searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014), MEDLINE (June 2011 to January 2014), EMBASE (June 2011 to January 2014), CINAHL (June 2011 to January 2014), Dissertations and Theses (June 2011 to January 2014), African Index Medicus, Latin American and Caribbean Health Sciences database, Virtual Health Library, Pan American Health Organization Database and the World Health Organization Library Information System. Database searches were conducted in January 2014. Selection criteria We searched for randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-after studies (CBAs) with at least two intervention and control sites, and interrupted-time-series (ITS) studies where the intervention time was clearly defined and there were at least three data points before and three after the intervention. We included two ITS studies that evaluated the effectiveness of organisational and professional interventions for reducing wrong-site surgery, including wrong-side and wrong-procedure surgery. Participants included all healthcare professionals providing care to surgical patients; studies where patients were involved to avoid the incorrect procedures or studies with interventions addressed to healthcare managers, administrators, stakeholders or health insurers. Data collection and analysis Two review authors independently assesses the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. Main results In the initial review, we included one ITS study that evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site tooth extractions. The intervention included examination of previous cases of wrong-site tooth extractions, educational intervention including a presentation of cases of erroneous extractions, explanation of relevant clinical guidelines and feedback by an instructor. Data were reported from all patients on the surveillance system of a University Medical centre in Taiwan with a total of 24,406 tooth extractions before the intervention and 28,084 tooth extractions after the intervention. We re-analysed the data using the Prais-Winsten time series and the change in level for annual number of mishaps was statistically significant at -4.52 (95% confidence interval (CI) -6.83 to -2.217) (standard error (SE) 0.5380). The change in slope was statistically significant at -1.16 (95% CI -2.22 to -0.10) (SE 0.2472; P < 0.05). This update includes an additional study reporting on the incidence of neurological WSS at a university hospital both before and after the Universal Protocol’s implementation. A total of 22,743 patients undergoing neurosurgical procedures at the University of Illionois College of Medicine at Peoria, Illinois, United States of America were reported. Of these, 7286 patients were reported before the intervention and 15,456 patients were reported after the intervention. The authors found a significant difference (P < 0.001) in the incidence of WSS between the before period, 1999 to 2004, and the after period, 2005 to 2011. Similarly, data were re-analysed using Prais-Winsten regression to correct for autocorrelation. As the incidences were reported by year only and the intervention occurred in July 2004, the intervention year 2004 was excluded from the analysis. The change in level at the point the intervention was introduced was not statistically significant at -0.078 percentage points (pp) (95% CI -0.176 pp to 0.02 pp; SE 0.042; P = 0.103). The change in slope was statistically significant at 0.031 (95% CI 0.004 to 0.058; SE 0.012; P < 0.05). Authors' conclusions The findings of this update added one additional ITS study to the previous review which contained one ITS study. The original review suggested that the use of a specific educational intervention in the context of a dental outpatient setting, which targets junior dental staff using a training session that included cases of wrong-site surgery, presentation of clinical guidelines and feedback by an instructor, was associated with a reduction in the incidence of wrong-site tooth extractions. The additional study in this update evaluated the annual incidence rates of wrong-site surgery in a neurosurgical population before and after the implementation of the Universal Protocol. The data suggested a strong downward trend in the incidence of wrong-site surgery prior to the intervention with the incidence rate approaching zero. The effect of the intervention in these studies however remains unclear, as data reflect only two small low-quality studies in very specific population groups.

Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part I: rapid review of SCI prioritisation literature.

Abstract: Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part I: rapid review of SCI prioritisation literature

Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate--A Single Institution Experience.

Abstract: Purpose: To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications. Patients and Methods: Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables). Results: There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an a...

A process evaluation accompanying an attempted randomized controlled trial of an evidence service for health system policymakers.

Abstract: Background: We developed an evidence service that draws inputs from Health Systems Evidence (HSE), which is a comprehensive database of research evidence about governance, financial and delivery arrangements within health systems and about implementation strategies relevant to health systems. Our goal was to evaluate whether, how and why a ‘full-serve’ evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care as compared to a ‘self-serve’ evidence service. Methods: We attempted to conduct a two-arm, 10-month randomized controlled trial (RCT), along with a followup qualitative process evaluation, but we terminated the RCT when we failed to reach our recruitment target. For the qualitative process evaluation we modified the original interview guide to allow us to explore the (1) factors influencing participation in the trial; (2) usage of HSE, factors explaining usage patterns, and strategies to increase usage; (3) participation in training workshops and use of other supports; and (4) views about and experiences with key HSE features. Results: We terminated the RCT given our 15% recruitment rate. Six factors were identified by those who had agreed to participate in the trial as encouraging their participation: relevance of the study to participants’ own work; familiarity with the researchers; personal view of the importance of using research evidence in policymaking; academic background; support from supervisors; and participation of colleagues. Most reported that they never, infrequently or inconsistently used HSE and suggested strategies to increase its use, including regular email reminders and employee training. However, only two participants indicated that employee training, in the form of a workshop about finding and using research evidence, had influenced their use of HSE. Most participants found HSE features to be intuitive and helpful, although registration/sign-in and some page formats (particularly the advanced search page and detailed search results page) discouraged their use or did not optimize the user experience. Conclusions: The qualitative findings informed a re-design of HSE, which allows users to more efficiently find and use research evidence about how to strengthen or reform health systems or in how to get cost-effective programs, services and drugs to those who need them. Our experience with RCT recruitment suggests the need to consider changing the unit of allocation to divisions instead of individuals within divisions, among other lessons. Trial registration: This protocol for this study is published in Implementation Science and registered with ClinicalTrials.gov (HHS/FHS REB 10–267).

Optimising return to work practices following catastrophic injury

Abstract: This paper aims to enhance understanding of the features of optimal return to work practices following traumatic brain and spinal cord injury and identify barriers and facilitators to their implementation. Executive summary People with catastrophic injuries face many long-term challenges in the community as a result of their injury: one of the most problematic can be in returning to work (RTW). It may not only be a significant issue for the person with a catastrophic injury but also for their family, friends, the employment industry, and society. Worldwide mean RTW rates for people with catastrophic injury are approximately 30-40%; however, in Australia the overall mean rate is unknown. Internationally, the best RTW rates reported for moderate to severe traumatic brain injury (TBI) come from the UK, Sweden and USA, whilst for spinal cord injury (SCI) they are in Switzerland and Sweden. There are several differences in the way rates reported are calculated such as the time post-injury, making it difficult to definitively identify whether one country achieves better RTW rates than another. Several studies have been conducted to determine the factors which facilitate and limit RTW for people with catastrophic injury. These include having pre-injury employment, age, education, severity of injury, level of cognitive impairment, being functionally independent, fatigue, psychological adjustment to the change, social support and the work environment to name a few. There is a general lack of understanding of the experience of people with catastrophic injury who return to work and, therefore, little known about how job retention can be successful in the long-term. Four types of VR interventions have been identified to facilitate RTW – 1) program based rehabilitation, 2) supported employment, 3) case co-ordination and 4) hybrid or mixed. An evidence review identified 15 relevant articles and it was found that there was limited high quality evidence to support any type of intervention more effective than the other. There was however moderate evidence identified for the effectiveness of case co-ordination for achieving successful RTW for people with moderate to severe TBI and high level evidence for a specialist TBI-VR combination intervention. A reduction in the claiming of benefits after 1 year was also observed. The most promising RTW intervention for people with SCI appears to be supported employment; however, as only one RCT has provided this evidence, further studies are required. Several factors that affect the likely success of RTW interventions were also identified in exploring the research evidence and implications for future research were identified. Substantial research has been conducted on RTW interventions in people with TBI since the late 1980s, however this is not the same for SCI. High quality evidence and transparent reporting of study details are still lacking. This NTRI Forum aims to enhance understanding of the features of optimal return to work practices following traumatic brain and spinal cord injury and identify barriers and facilitators to their implementation. Two questions were identified for deliberation in a Stakeholder Dialogue: 1. In the Australian context, what are the barriers to, and facilitators of, application of strategies to optimise RTW outcomes for people with catastrophic injury? 2. How could identified barriers and facilitators be addressed to ensure successful RTW and better retention of people with catastrophic injury? An accompanying document (Dialogue Summary) will present the results of the deliberation upon these questions

Optimising self-directed funding for the long-term disabled: briefing document

Abstract: People with long-term disabilities have become increasingly frustrated with the inadequate support services provided by the disability sector. In particular, people with long-term disabilities want to have support services which met their needs as well as greater choice and control in the decisions around them. Over the last five years the popularity of self-directed funding has increased significantly. In 2011/12 the Australian Government made a commitment to implement a National Disability Insurance Scheme (NDIS) as advised through an inquiry by the Productivity Commission to have full rollout country wide by 2018. Self-directed funding is used as a mechanism to promote self-determination and empowerment in people with long-term disabilities and to facilitate their living in the community independently. Self-directed funding can be provided by an individual package held by a provider, by an individual budget held by the person to spend through providers or by direct payments to spend on the open market. The implementation of self-directed funding models has been implemented in various forms over the past couple of decades, including the piloting of small scale programs and the introduction of larger scale programs by government bodies or departments in specific disability groups. Self-directed funding models are strongly established in the UK, USA and Western Australia. The inclusion of infrastructure supports such as independent brokers, financial intermediaries and ongoing support for clients are beneficial features of established models, particularly for people with complex needs. Despite their popularity, there is a lack of evidence about the effectiveness of self-directed funding models in practice, and no evidence comparing different models. No single model has been demonstrated to be superior to another, likely in part because the cultural and political context in which a scheme is introduced has a strong influence on its design, implementation and outcomes. Despite this, there are consistent indications that offering flexible and creative options within models is the best approach for ensuring people with more complex and potentially unmet needs, have an opportunity to take up self-directed funding successfully. There are limited studies of the feasibility and impact of self-directed funding for people in the compensable sector with catastrophic injuries. Qualitative studies using interviews or questionnaires reveal that, generally, people with long-term disabilities recognise that self-directed funding should be one option among the range of options for receiving necessary support services; however, there is variability in the stated willingness to take on self-directed funding themselves. A lack of awareness of what is involved in self-directed funding and how it can be managed has been reported. In addition, it has been suggested that not all people have the skills, education or experience to manage self-directed funding, hence training and information sessions that are understandable and comprehensive are likely to be necessary in order to encourage uptake. This NTRI Forum aims to consider the factors which influence the uptake of self-directed funding by the long-term disabled. Two questions were identified for deliberation in a Stakeholder Dialogue: 1. What are the barriers and facilitators to optimal implementation and uptake of self- directed funding in Australia and New Zealand? 2. How can knowledge of barriers and facilitators be used to address these challenges?