The purpose of this thesis was to determine the feasibility of implementing an intervention tailored to overcome barriers to adherence to recommendations of critical care nutrition guidelines in the Intensive Care Unit (ICU). The thesis is comprised of four manuscripts. The first manuscript described the development of a 26 item questionnaire rating the importance of potential barriers as impediments to the provision of enteral nutrition (EN) in the ICU. Preliminary evaluation demonstrated acceptable face and content validity and internal reliability, but the test retest reliability and within group reliability were poor for some items. The second manuscript provided evidence to support the construct validity of the developed questionnaire by reporting the results of a multilevel multivariate regression analysis of cross-sectional data from 55 ICUs that demonstrated that a 10 point increase in the overall barrier score was associated with a statistically significant 3.5% (Standard Error (SE) 1.3) decrease in prescribed calories received from EN. The third manuscript provided data to inform whether the intervention should be tailored to site specific barriers by describing the barriers to enterally feeding critically ill patients identified by 138 nurses, and evaluating whether these barriers differed across the 5 participating sites. Statistically significant differences were found among ICUs for 4 out of the 22 potential barriers. The fourth manuscript described the results of a pretest posttest study involving 5 ICUs in North America and determined that all participating sites successfully developed the tailored intervention. A statistically significant 10% (Site range -4.3 to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5 to17.9%) change in prescribed calories received was observed following the intervention. However, there was variability in the degree of implementation achieved by each site. Taken together, the results of this thesis demonstrated that adopting a tailored approach to improving nutrition practice is feasible. However, the findings also resulted in revisions to the barriers questionnaire and modifications to the design of the tailored intervention. Thus, the next step is to formally test the hypothesis that a tailored intervention designed to address barriers to feeding critically ill patients will improve nutrition performance. / Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2013-04-28 21:37:54.695

Neonatal mortality remains a problem worldwide, despite the existence of low-cost and evidence-based interventions. Unfortunately, the translation of these interventions into practice is deficient. The aim of this thesis was to study aspects of knowledge translation (KT) before and during the Neonatal Knowledge Into Practice (NeoKIP) trial in Quang Ninh, Vietnam. Over a period of three years, this trial evaluated the use of facilitators from the Women’s Union who supported maternal and newborn health groups (MNHG) comprised of eight local stakeholders, as an intervention for improved neonatal survival. In the first two studies (before intervention) we assessed primary health care staff’s knowledge and material preparedness regarding evidence-based neonatal care and explored how primary health care staff translated knowledge into practice. The last two studies (during intervention) were process evaluations aimed at describing the implementation, process and mechanism of the NeoKIP intervention. Primary health care workers achieved 60% of the maximum score in the knowledge survey. Two separate geographical areas were identified with differences in staff levels of knowledge and concurrent disparities in neonatal survival, antenatal care and post-natal home visits. Staff perceived formal training to be the best way to acquire knowledge but asked for more interaction between colleagues within the healthcare system. Traditional medicine, lack of resources, low workload and poorly paid staff constituted barriers for the development of staff knowledge and skills. Eleven facilitators were trained to cover eight facilitator positions. Of the 44 MNHGs, 43 completed their activities to the end of the study. In total, 95% of the monthly meetings with a MNHG and a facilitator were conducted with attendance at 86%. MNHGs identified 32 unique problems, mainly families’ knowledge/behavior, and implemented 39 unique actions, mostly regarding communication. MNHGs experienced that the group was strategically composed to influence change in the communes and facilitators were identified as being important to sustaining activities over time. The facilitators’ lack of health knowledge was regarded as a deficit in assisting the MNHGs, but their performance and skills increased over time. This low-cost model, building on local stakeholder involvement, has the capacity to be scaled up within existing healthcare structures.

The Canadian C-Spine (CS) and CT-Head (CT) Rules are tools aimed at improving the accuracy and efficiency of radiography use in emergency departments. This study evaluated whether the Theory of Planned Behaviour (TPB) could explain the inconsistent results from implementation studies of these two rules at 12 Canadian hospitals, where the same intervention resulted in a significant reduction in CS radiography but not CT radiography. It was demonstrated that the TPB model’s proposed relationships between constructs and behaviour could explain the ordering of CS but not CT radiography. However, after examining longitudinal changes of the TPB constructs, it was clear that these changes could not explain the changes in CS radiography ordering. Overall, TPB is unlikely to suggest important ways by which to improve radiography use, for CT because its constructs are not related to radiography ordering, and for CS because of high baseline levels of intention to clinically clear.

The purpose of this thesis is to apply the Promoting Action on Research Implementation in Health Services (PARiHS) framework to a provincial osteoporosis management program to describe unit level factors that may have influenced implementation among participating inpatient rehabilitation units. A toolbox of measures was proposed to operationalize the frameworks elements of evidence, context and facilitation. A cross-sectional survey was completed with clinicians responsible for championing the program and their managers. Results demonstrated that leadership behaviours, organizational climate traits and champion behaviours varied among practice environments indicating that attention to unit level factors outlined by the PARiHS framework could increase the uptake of research evidence in practice. The proposed toolbox could be utilized as a diagnostic and prescriptive tool to identify potential implementation barriers, and guide the selection of appropriate tools/strategies to overcome them. Furthermore, it will enable future studies to provide further empirical support for the PARiHS framework

Background: The neurological examination in critically ill patients is limited due to decreased level of consciousness and sedating medications. Electroencephalography (EEG) can be used to monitor brain injury; however, availability is limited. Methods: To determine the perceived need for EEG monitoring in the ICU and its current availability, we used rigorous methodology to develop and disseminate a survey to 199 Canadian critical care physicians. Results: Of 103 (52%) respondents (77% academic practice; 83% adult focus), 75% stated EEG monitoring should be a standard of care; yet, 75.5% were unable to obtain an EEG in an optimal timeframe. Technology under-use was exacerbated during non-standard working hours and greater in adult institutions. Perceived barriers to optimal care were lack of EEG technicians, physicians to interpret EEG and finances. Conclusion: Sub-optimal availability of EEG represents an important gap in the care of neurologically injured patients. Specific barriers represent targets for quality improvement.

Background: The neurological examination in critically ill patients is limited due to decreased level of consciousness and sedating medications. Electroencephalography (EEG) can be used to monitor brain injury; however, availability is limited. Methods: To determine the perceived need for EEG monitoring in the ICU and its current availability, we used rigorous methodology to develop and disseminate a survey to 199 Canadian critical care physicians. Results: Of 103 (52%) respondents (77% academic practice; 83% adult focus), 75% stated EEG monitoring should be a standard of care; yet, 75.5% were unable to obtain an EEG in an optimal timeframe. Technology under-use was exacerbated during non-standard working hours and greater in adult institutions. Perceived barriers to optimal care were lack of EEG technicians, physicians to interpret EEG and finances. Conclusion: Sub-optimal availability of EEG represents an important gap in the care of neurologically injured patients. Specific barriers represent targets for quality improvement.

The purpose of this thesis is to apply the Promoting Action on Research Implementation in Health Services (PARiHS) framework to a provincial osteoporosis management program to describe unit level factors that may have influenced implementation among participating inpatient rehabilitation units. A toolbox of measures was proposed to operationalize the frameworks elements of evidence, context and facilitation. A cross-sectional survey was completed with clinicians responsible for championing the program and their managers. Results demonstrated that leadership behaviours, organizational climate traits and champion behaviours varied among practice environments indicating that attention to unit level factors outlined by the PARiHS framework could increase the uptake of research evidence in practice. The proposed toolbox could be utilized as a diagnostic and prescriptive tool to identify potential implementation barriers, and guide the selection of appropriate tools/strategies to overcome them. Furthermore, it will enable future studies to provide further empirical support for the PARiHS framework

Background: The neurological examination in critically ill patients is limited due to decreased level of consciousness and sedating medications. Electroencephalography (EEG) can be used to monitor brain injury; however, availability is limited. Methods: To determine the perceived need for EEG monitoring in the ICU and its current availability, we used rigorous methodology to develop and disseminate a survey to 199 Canadian critical care physicians. Results: Of 103 (52%) respondents (77% academic practice; 83% adult focus), 75% stated EEG monitoring should be a standard of care; yet, 75.5% were unable to obtain an EEG in an optimal timeframe. Technology under-use was exacerbated during non-standard working hours and greater in adult institutions. Perceived barriers to optimal care were lack of EEG technicians, physicians to interpret EEG and finances. Conclusion: Sub-optimal availability of EEG represents an important gap in the care of neurologically injured patients. Specific barriers represent targets for quality improvement.

Background: The neurological examination in critically ill patients is limited due to decreased level of consciousness and sedating medications. Electroencephalography (EEG) can be used to monitor brain injury; however, availability is limited. Methods: To determine the perceived need for EEG monitoring in the ICU and its current availability, we used rigorous methodology to develop and disseminate a survey to 199 Canadian critical care physicians. Results: Of 103 (52%) respondents (77% academic practice; 83% adult focus), 75% stated EEG monitoring should be a standard of care; yet, 75.5% were unable to obtain an EEG in an optimal timeframe. Technology under-use was exacerbated during non-standard working hours and greater in adult institutions. Perceived barriers to optimal care were lack of EEG technicians, physicians to interpret EEG and finances. Conclusion: Sub-optimal availability of EEG represents an important gap in the care of neurologically injured patients. Specific barriers represent targets for quality improvement.

The Canadian C-Spine (CS) and CT-Head (CT) Rules are tools aimed at improving the accuracy and efficiency of radiography use in emergency departments. This study evaluated whether the Theory of Planned Behaviour (TPB) could explain the inconsistent results from implementation studies of these two rules at 12 Canadian hospitals, where the same intervention resulted in a significant reduction in CS radiography but not CT radiography. It was demonstrated that the TPB model’s proposed relationships between constructs and behaviour could explain the ordering of CS but not CT radiography. However, after examining longitudinal changes of the TPB constructs, it was clear that these changes could not explain the changes in CS radiography ordering. Overall, TPB is unlikely to suggest important ways by which to improve radiography use, for CT because its constructs are not related to radiography ordering, and for CS because of high baseline levels of intention to clinically clear.