Effects of computer reminders on complications of peripheral venous catheters and nurses’ adherence to a guideline in paediatric care—a cluster randomised study

Implementation Science

Anna Ehrenberg²  Britt-Marie Ygge⁵  Max Petzold¹  Lars Wallin⁴  Maria Unbeck³  Ulrika Förberg⁵ 

[1]Karolinska Institutet, ICHAR, Stockholm, Sweden

[2]School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

[3]Division of Orthopaedics, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

[4]Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden

[5]Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Elevhemmet H2:00, 171 76, Stockholm, Sweden

关键词: Context;    Implementation;    Cluster RCT;    Clinical practice guideline;    Paediatric;    Computer reminder;    Clinical decision support system;    Peripheral venous catheter;   

Others  :  1235786
DOI  :  10.1186/s13012-016-0375-9

 received in 2015-07-07, accepted in 2016-01-21,  发布年份 2016

【 摘 要 】

Background

Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals’ behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses’ (RNs’) self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention.

Methods

The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs’ adherence to a PVC guideline, collected through a questionnaire that also included RNs’ perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention.

Results

No significant effect was found for the computer reminders on PVC-related complications nor on RNs’ adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7–44.5) and 41.9 % (95 % CI 38.0–45.8), for the intervention group and 40.3 % (95 % CI 36.8–44.0) and 46.9 % (95 % CI 43.1–50.7) for the control. In general, RNs’ self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal.

Conclusions

The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs.

Trial registration

Current Controlled Trials ISRCTN44819426

【 授权许可】

   
2016 Förberg et al.

【 图 表 】

Fig. 1.

【 参考文献 】

• [1]Pettit J. Assessment of the infant with a peripheral intravenous device. Advances in Neonatal Care. 2003; 3(5):230-40.
• [2]Reigart JR, Chamberlain KH, Eldridge D, O'Brien ES, Freeland KD, Larsen P et al.. Peripheral intravenous access in pediatric inpatients. Clinical Pediatrics. 2012; 51:468-72.
• [3]O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO et al.. Guidelines for the prevention of intravascular catheter-related infections. American Journal of Infection Control. 2011; 39 Suppl 1:S1-34.
• [4]Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implementation science. 2012; 7:50. BioMed Central Full Text
• [5]Gabbay J, Le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. British Medical Journal. 2004; doi: http://dx.doi.org/10.1136/bmj.329.7473.1013
• [6]Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care. 1998; 7:149-58.
• [7]Rycroft-Malone J, Kitson A, Harvey G, McCormack B, Seers K, Titchen A et al.. Ingredients for change: revisiting a conceptual framework. Quality & Safety in Health Care. 2002; 11:174-80.
• [8]Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implementation science. 2008; 3:1. BioMed Central Full Text
• [9]McCormack B, Kitson A, Harvey G, Rycroft-Malone J, Titchen A, Seers K. Getting evidence into practice: the meaning of ‘context’. Journal of Advanced Nursing. 2002; 38:94-104.
• [10]Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implementation Science. 2009; 4:38. BioMed Central Full Text
• [11]Rycroft-Malone J, Seers K, Chandler J, Hawkes CA, Crichton N, Allen C et al.. The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework. Implementation Science. 2013; 8:28. BioMed Central Full Text
• [12]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009; 4:50. BioMed Central Full Text
• [13]Gordon RB, Grimshaw JM, Eccles MP, Rowe RE, Wyatt JC. On-screen computer reminders: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews. 1998.
• [14]Choi M, Choi R, Bae Y, Lee S. Clinical decision support systems for patient safety, a focus group need assessment with Korean ICU nurses. Computers, Informatics, Nursing. 2011; 29:671-678.
• [15]Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J et al.. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. The Journal of the American Medical Association. 2005.
• [16]Randell R, Mitchell N, Dowding D, Cullum N, Thompson C. Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review. Journal of Health Services Research & Policy. 2007; 12:242-9.
• [17]Anderson JA, Willson P. Clinical decision support systems in nursing: synthesis of the science for evidence-based practice. Computers, Informatics, Nursing. 2008; 26:151-8.
• [18]Fossum M, Ehnfors M, Svensson E, Hansen LH, Ehrenberg A. Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: an intervention study. International Journal of Medical Informatics. 2013; 82:911-21.
• [19]Cho I, Park I, Kim E, Lee E, Bates DW. Using EHR data to predict hospital-acquired pressure ulcers: a prospective study of a Bayesian Network model. International Journal of Medical Informatics. 2013; 82:1059-67.
• [20]Lyerla F. Design and implementation of a nursing clinical decision support system to promote guideline adherence. Computers, Informatics, Nursing. 2008; 26:227-33.
• [21]Piscotty RJ, Jr KB. The relationship between electronic nursing care reminders and missed nursing care. Computers, Informatics, Nursing. 2014; 32:475-81.
• [22]Forberg U, Johansson E, Ygge BM, Wallin L, Ehrenberg A. Accuracy in documentation of peripheral venous catheters in paediatric care: an intervention study in electronic patient records. Journal of Clinical Nursing. 2012; 21:1339-44.
• [23]Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L et al.. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004; 8:1-72.
• [24]Donner A, Klar N. Design and analysis of cluster randomization trials in health research. London: Edward Arnold; 2000.
• [25]Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta Context Tool. BMC Health Services Research. 2009;9:234.
• [26]Estabrooks CA, Squire J, Adachi A, Kong LPGN. Utilization of health research in acute care settings in Alberta Technical Report. Alberta: University of Alberta, Canada; 2008.
• [27]Cummings GG, Hutchinson AM, Scott SD, Norton PG, Estabrooks CA. The relationship between characteristics of context and research utilization in a pediatric setting. BMC Health Services Research. 2010;10:168.
• [28]Estabrooks CA, Squires JE, Hutchinson AM, Scott S, Cummings GG, Kang SH, et al. Assessment of variation in the Alberta Context Tool: the contribution of unit level contextual factors and specialty in Canadian pediatric acute care settings. BMC Health Service Research. 2011;11:251.
• [29]Scott SD, Grimshaw J, Klassen TP, Nettel-Aguirre A, Johnson DW. Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol. Implementation Science. 2011;6:133.
• [30]Squires JE, Estabrooks CA, Scott SD, Cummings GG, Hayduk L, Kang SH, et al. The influence of organizational context on the use of research by nurses in Canadian pediatric hospitals. BMC Health Service Research. 2013;13:351.
• [31]Eldh AC, Ehrenberg A, Squires JE, Estabrooks CA, Wallin L. Translating and testing the Alberta Context Tool for use among nurses in Swedish elder care. BMC Health Services Research, 13:68. 2013;13:478
• [32]Squires JE, Hutchinson AM, Hayduk L, Cranley L, Cummings G, Norton PG, et al. Alberta Context Tool: user manual. Knowledge Utilization Studies Program: Faculty of Nursing, University of Alberta, Edmonton, Canada; 2014. ISBN 978-1-55195-340-3.
• [33]Forberg U, Wallin L, Johansson E, Ygge BM, Backheden M, Ehrenberg A. Relationship between work context and adherence to a clinical practice guideline for peripheral venous catheters among registered nurses in pediatric care. Worldviews on Evidence-Based Nursing. 2014;11:227–39.
• [34]Wallin L, Estabrooks CA, Midodzi WK, Cummings GG. Development and validation of a derived measure of research utilization by nurses. Nursing Research. 2006;55:149–60.
• [35]Cummings GG, Estabrooks CA, Midodzi WK, Wallin L, Hayduk L. Influence of organizational characteristics and context on research utilization. Nursing Research. 2007;56(Suppl 1):24–39.
• [36]Roshanov PS, Fernandes N, Wilczynski JM, Hemens BJ, You JJ, Handler SM, et al. Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials. British Medical Journal. 2013;346:f657.
• [37]Squires JE, Sullivan K, Eccles MP, Worswick J, Grimshaw JM. Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews. Implementation Science. 2014;9:152.
• [38]Fossum M, Ehnfors M, Svensson E, Hansen LH, Ehrenberg A. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. International Journal of Medical Informatics. 2011;80:607–17.
• [39]Hagiwara MA, Sjoqvist BA, Lundberg L, Suserud BO, Henricson M, Jonsson A. Decision support system in prehospital care: a randomized controlled simulation study. The American Journal of Emergency Medicine. 2013;31:145–53.
• [40]Beeckman D, Clays E, Van Hecke A, Vanderwee K, Schoonhoven L, Verhaeghe S. A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled trial. International Journal of Nursing Studies. 2013;50:475–86.
• [41]Eldh AC, Tollne A, Förberg U, Wallin L. What registered nurses do and do not in the management of pediatric peripheral venous catheters and guidelines: unpacking the outcomes of computer reminders. Worldviews on Evidence-Based Nursing. 2016; 20. doi:10.1111/wvn.12130.
• [42]Gifford WA, Davies BL, Graham ID, Tourangeau A, Woodend AK, Lefebre N. Developing leadership capacity for guideline use: a pilot cluster randomized control trial. Worldviews on Evidence-Based Nursing. 2013; 10:51-65.
• [43]Unbeck M, Förberg U, Ygge BM, Ehrenberg A, Petzold M, Johansson E. Peripheral venous catheter related complications are common among paediatric and neonatal patients. Acta Paediatrica. 2015; 104:566-74.
• [44]Nichols A. An investigation of the division between espoused and actual practise in infection control and of the knowledge sources that may underpin this division. British Journal of Infection Control. 2008; 9:11-5.