Implementation and evaluation of a validated evidence-based physiotherapy protocol in a surgical icu : a controlled before and after study

Karachi, Farhana (2018-12)

Thesis (PhD)--Stellenbosch University, 2018.

Thesis

ENGLISH SUMMARY : Overall Aim: to implement and evaluate a tailored best-practice multifaceted implementation strategy (intervention) for the effective uptake of a validated evidence-based physiotherapy protocol for the management of patients in a surgical intensive care unit (ICU) in the Western Cape, South Africa (SA). Method: A phased, multipronged design. Phase 1 (survey): described i) the profile of the public sector physiotherapists and their department organisation and structure and ii) the profile and current practices of the public ICU physiotherapists and ICU organisation and structure in which they work. Phase 2 (systematic review): identified best-practice implementation strategies for the effective uptake of evidence-based clinical practice guidelines (CPGs) and protocols. Phase 3a) Nominal Group Technique (NGT): tailored the implementation strategies to the targeted physiotherapists; and b) controlled before and after (CBA) trial: implemented and evaluated the intervention for the uptake of the ICU physiotherapy protocol in a surgical ICU. Results: The physiotherapy survey received a 70% (n=46/66) response. 429 young, early-career physiotherapists with mainly Bachelor degrees, in production (‘junior’) level posts, in departments organised and structured on a departmental model with a hierarchal ranking of posts and physiotherapy to hospital bed ratio of 1:69 was identified. The ICU physiotherapy survey received a 34% (n=58/170) response. ICU physiotherapists had no ICU post-graduate training, 1-5years of ICU work experience, ICU services and practices that varied. Education, audit and feedback, reminders, support, multidisciplinary implementation team and plan, communication and case discussion including telemedicine strategies were identified. Multifaceted implementation strategies are four times more effective (OR: 4.07, 95%CI: 2.93-5.65; p<0.00001, I=89%) than single strategies in improving process of care measures in the ICU. The tailored intervention included an educational handbook, workshop series, grand rounds/bedside teaching sessions and reminders (pocket cards and posters). 1509 patients were included in the 16month CBA trial analysis. Experimental Unit A had a higher TISS-28unit day score [2.3units, p=0.004] in the implementation phase compared to the baseline (pre-implementation phase) in Unit A and all phases in control Unit B. Time to first physiotherapy contact after ICU admission in the implementation phase was longer [adj. OR 1.2, 95%CI:1-1.4, p=0.02] in Unit A than the pre-implementation phase and pre-and implementation phase in Unit B. There was no change in time to first physiotherapy [adj. OR 0.9, 95%CI:0.7-1.1, p=0.19] and first nurse [adj. OR 1, 95%CI: 0.7-1.6, p=0.84] mobilisation into a chair after ICU admission and time to physiotherapy post-extubation [adj. OR 1, 95%CI: 0.9-1.2, p=0.83] in the implementation phase regardless of unit and phase. Patients in unit A were more likely to receive the physiotherapy process of care than patients in unit B at baseline. There was no difference in hospital mortality [adj. OR 1.1, 95%CI: 0.6 - 2, p = 0.78], ICU mortality [adj. OR 1.22, 95%CI: 0.59 - 2.52, p=0.59], intubation [adj. OR 1.1, 95%CI: 0.8 - 1.5, p=0.68] nor proportion of failed extubations [adj. OR 1.2, 95%CI: 0.8 – 2, p=0.39] in the implementation phase between Unit A and B. Conclusion: A tailored best-practice multifaceted implementation strategy and implementation fidelity alone did not facilitate effective uptake of and adherence to the protocol. ICU physiotherapy profile, organisation and structure and practice variation, high baseline process of care adoption rates, healthcare professional behaviour, attitude, knowledge and self-efficacy influenced protocol adherence. The use of a framework to guide ICU implementation initiatives and contextualize the implementation process in a resource limited setting is supported.

AFRIKAANSE OPSOMMING : Oorhoofse doelwit: Implementering en evalueering van 'n pasgemaakte, beste-praktyk, veelvlakkige implementeringstrategie (intervensie) vir die effektiewe opname van 'n gevalideerde bewysgebaseerde fisioterapieprotokol vir die bestuur van pasiënte in 'n chirurgiese intensiewe sorgeenheid (ICU) in die Wes-Kaap, Suid Afrika (SA). Metode: 'N Fase, veelvoudige ontwerp. Fase 1 (opname): beskryf i) die profiel van die openbare sektor fisioterapeute en hul departement organisasie en struktuur en ii) die profiel en huidige praktyke van die openbare ICU fisioterapeute en ICU organisasie en struktuur waarin hulle werk. Fase 2 (sistematiese oorsig): bestepraktyk implementeringstrategieë vir die effektiewe opname van bewysgebaseerde kliniese praktyk riglyne (GPG's) en protokolle was geïdentifiseer. Fase 3a) Nominale Groeptegniek (NGT): Die implementeringstrategieë vir die geteikende fisioterapeute is aangepas; en b) beheer voor en na (CBA) verhoor: die intervensie vir die opname van die intensiewe sorg fisioterapie protokol in 'n chirurgiese intensiewe sorgeenheid was geïmplementeer en geëvalueer. Resultate: Die fisioterapie opname vraelys het 'n 70% (n = 46/66) reaksie ontvang. 429 jong, vroeë loopbaanfisioterapeute met hoofsaaklik Baccalaureusgrade, in produksie ('junior') vlakposte, in afdelings georganiseer en gestruktureer op 'n departementele model met 'n hiërargiese rangorde van poste en fisioterapie tot hospitaalbedverhouding van 1:69, is geïdentifiseer. Die intensiewe sorgeenheid fisioterapie opname vraelys het 'n 34% (n = 58/170) reaksie ontvang. Intensiewe sorgeenheid fisioterapeute het geen intensiewe sorg nagraadse opleiding gehad nie, 1-5jaar van intensiewe sorg werkservaring, intensiewe sorgeenheid dienste en praktyke wat wissel. Onderwys, oudit en terugvoer, herinnerings, ondersteuning, multi-dissiplinêre implementeringspan en plan, kommunikasie en gevallestudie, insluitend telemedisynstrategieë, is geïdentifiseer. Veelvlakkige implementeringstrategieë is vier keer meer effektief (OR: 4.07, 95% CI: 2.93-5.65; p <0.00001, I = 89%) as enkele strategieë om die proses van versorgingsmaatreëls in die intensiewe sorgeenheid te verbeter. Die aangepaste intervensie het 'n opvoedkundige handboek, werkswinkelreeks, wyk ronde/bedkant-lesings en onthounotas (sakkaarte en plakkate) ingesluit. 1509 pasiënte is ingesluit in die 16-maande CBA proef analise. Eksperimentele Eenheid A het 'n hoër TISS-28 eenheidspunt [2.3 eenhede, p = 0.004] in die implementeringsfase in vergelyking met die basislyn (pre-implementeringsfase) in Eenheid A en alle fases in beheer Eenheid B gehad. Tyd tot eerste fisioterapie kontak na intensiewe sorgeenheids toelating in die implementeringsfase was langer [adj. OR 1.2, 95% CI: 1-1.4, p = 0.02] in Eenheid A as die voor-implementeringsfase en voor- en implementeringsfase in Eenheid B. Daar was geen verandering in tyd vir eerste fisioterapie [adj. OR 0.9, 95% CI: 0.7-1.1, p = 0.19] en eerste verpleegster [adj. OR 1, 95% CI: 0.7-1.6, p = 0.84] mobilisering in 'n stoel na die intensiewe sorgeenheid toelating en tyd na fisioterapie na extubasie [adj. OR 1, 95% CI: 0.9-1.2, p = 0.83] in die implementeringsfase nie, ongeag van eenheid en fase. Pasiënte in Eenheid A was meer geneig om die fisioterapie sorg proses te ontvang as pasiënte in eenheid B by basislyn. Daar was geen verskil in hospitaalsterfte [adj. OR 1.1, 95% CI: 0.6 - 2, p = 0.78], intensiewe sorg sterfte [adj. OR 1.22, 95% CI: 0.59 - 2.52, p = 0.59], intubasie [adj. OR 1.1, 95% CI: 0.8 - 1.5, p = 0.68] of proporsie van mislukte ekstubasies [adj. OR 1.2, 95% CI: 0.8 - 2, p = 0.39] in die implementeringsfase tussen Eenhede A en B. Gevolgtrekking: 'n Gepaste, beste-praktyk, veelvlakkige implementeringstrategie en implementeringstrouheid het nie die effektiewe opname en aaneming van die protokol vergemaklik nie. Die intensiewe sorg fisioterapie profiel, organisasie en struktuur en praktyk variasie, hoë basislyn sorg proses aaneming, gesondheidsorg professionele gedrag, houding, kennis en selfdoeltreffendheid het the aaneming van die protokol beïnvloed. Die gebruik van 'n raamwerk om intensiewe sorg implementeringsinisiatiewe te rig en die implementeringsproses in 'n hulpbron beperkte omgewing te kontekstualiseer, word ondersteun.

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