- Title
- One size does not fit all: the development, and execution of, a tailored implementation approach to improve evidence-based patient blood management
- Creator
- Delaforce, Alana
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2022
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Background: Blood transfusions are associated with adverse outcomes. The decision to administer a blood transfusion should consider whether the clinical benefit to the patient outweighs the associated risks. In the surgical population, transfusion avoidance is achieved by applying the principles outlined in the perioperative module of the Australian National Blood Authorities’ Patient Blood Management (PBM) guidelines. One of those principles includes the implementation of Preoperative Anaemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P). To date, the uptake of PAIDSEM-P has been variable, and facilities that have demonstrated success do not report their approach clearly. Due to poor reporting, it remains unclear if and how implementation theories and frameworks can help improve PAIDSEM-P uptake. Aims: To undertake a knowledge translation project to improve the uptake of recommended Patient Blood Management practices. Methods: The research occurred in four distinct phases using multiple methods. The Knowledge To Action (KTA) framework guided the implementation process. Phase One: Three retrospective medical chart audits diagnosed local practice gaps. The first audit analysed compliance with PBM guidelines in elective orthopaedic and colorectal surgical patients who had received a blood transfusion. Two subsequent audits report the broader prevalence of preoperative anaemia and compliance with the completion of recommended screening, testing, evaluation and management of anaemia and iron deficiency. Phase Two: A restricted systematic review established the current evidence base of barriers to implementing PBM guidelines and theoretically informed strategies to address them. It used the Consolidated Framework for Implementation Research (CFIR) to identify common barriers experienced by health facilities when implementing Patient Blood Management (PBM) guidelines and compared strategies reported in the evidence with the Expert Recommendations for Implementing Change (ERIC) tool recommendations. Phase Three: A qualitative investigation using semi-structured interviews conducted with 15 respondents identified local barriers to patient blood management guideline implementation. Barriers were coded using the Consolidated Framework for Implementation Research (CFIR) and mapped to the Expert Recommendations for Implementing Change (ERIC) tool to inform implementation strategy selection. Phase Four: A before and after observational study, using a type two-hybrid effectiveness implementation approach, evaluated the impact of a theoretically informed change package to improve the uptake of Preoperative Anaemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P). The change package consisted of the PAIDSEM-P delivered by a preoperative anaemia coordinator. To determine the effectiveness of the change package, 400 patient charts were reviewed (200 pre and 200 post-implementation). A validated survey instrument administered to hospital staff helped evaluate the pathway's acceptability, appropriateness, and feasibility. Results: Phase one: Forty-two percent (42%) of transfused patients were identified as having preoperative anaemia following major, elective orthopaedic or gastrointestinal surgery. Only twenty-one percent (21%) of those patients had iron studies performed, demonstrating suboptimal compliance with the recommendation to screen patients for anaemia and iron deficiency preoperatively. Subsequent audits which analysed the broader population of orthopaedic and colorectal surgery patient experience found 14.6% and 36% of patients were anaemic preoperatively (respectively), and only 5.9% and 25% (respectively) of those received treatment. Those who were anaemic preoperatively were more likely to receive a blood transfusion (OR 8.65 [95% CI 3.980-18.76]) and stayed longer in hospital (median difference = 1, x2 LR = 17.2, df=1, p<0.007). Phase Two: The systematic review uncovered a cluster of common barriers, including access to knowledge and information, knowledge and beliefs about the intervention and tension for change. Implementation strategies used to address them varied widely, but most studies had at least 50% agreement with the ERIC recommendations. The review also found that included studies did not clearly report their implementation efforts. Phase Three: The qualitative investigation revealed five common barriers, including access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention, available resources, and networks and communications. Barriers mapped to the ERIC framework revealing the following strategies as being potentially appropriate to overcome them including: conduct educational meetings, develop educational materials, distribute educational materials, obtain and use patients/consumers family feedback, involve patients/consumers/family members, conduct a local needs assessment, access new funding, promote network weaving, and organize clinician implementation team meetings. Phase Four: Post-implementation of a theoretically informed change package, the odds of patients being screened for preoperative anaemia and iron deficiency were over ten times higher relative to pre-implementation (Odds Ratio 10.6 [95% CI 4.4-25.5] p<0.001). Clinical outcomes remained unchanged post implementation with patients no less likely to be anaemic on the day of surgery (Odds Ratio 0.8 [95% CI 0.5-1.3] p=0.32) or receive a transfusion (Odds Ratio 0.8 [95% CI 0.4-1.7] p=0.62). After accounting for the cost of the coordinator, the study demonstrated savings of $13,340 per patient based on the care as delivered. Ten of eleven survey participants agreed or completely agreed that the intervention was acceptable and appropriate, with one staff member responding that they neither agreed nor disagreed. All eleven participants agreed or completely agreed that the pathway was feasible. Conclusion: This project diagnosed practice gaps and developed a theoretically informed change package that successfully addressed them. Significant improvements were made in the use of evidence-based blood management practices, and there were cost savings generated from the study in the post-implementation group. More data is needed to demonstrate the clinical impact of the PAIDSEM-P on reducing transfusion rates and the number of patients with anaemia or iron deficiency on the day of surgery. The Knowledge to Action framework was helpful as a process model for implementation, and the use of the CFIR, ERIC and AACTT implementation frameworks supported a robust improvement plan. Implementation approaches using these frameworks should be generalisable to other evidence-based practice gaps and assist health facilities wishing to improve practice.
- Subject
- implementation; blood; ERIC; knowledge to action; AACTT; outcomes; thesis by publication; anaemia; anemia; PAIDSEM-P; improvement; transfusion; qualitative; quantitative; CFIR
- Identifier
- http://hdl.handle.net/1959.13/1504004
- Identifier
- uon:55431
- Rights
- Copyright 2022 Alana Delaforce
- Language
- eng
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