SeriesFrom best evidence to best practice: effective implementation of change in patients' care
Section snippets
How do characteristics of evidence affect its uptake?
Characteristics of research evidence might affect whether it is used in clinical practice. Some research findings are easily adopted. For example, conservative treatment in children with acute otitis media proved to be as effective as myringotomy. Publication of this finding in a scientific journal was sufficient for almost all doctors to stop doing this procedure within a short time, probably because the study was triggered by practitioners' scepticism of the benefits of the established
Complexity of performance change: the case of hand hygiene
Reduction in hospital-acquired infections is one of the priorities in health care in many countries. These infections are estimated to affect about one in 11 patients, with 13% mortality and a lengthened stay in hospital of a factor of 2·5.22 The extra cost per patient with an infection in the UK is about £3000. Between 15% and 30% of infections are considered preventable—eg, by improved hand hygiene.
We have been aware of the importance of handwashing since the mid 1800s, when Ignaz Philipp
Barriers and facilitators to evidence uptake
Analyses of barriers to changing practice, such as a review of 76 studies in doctors,28 have shown that obstacles to change in practice can arise at different stages in the health-care system, at the level of the patient, the individual professional, the health-care team, the health-care organisation, or the wider environment.29, 30, 31 Most theories on implementation of evidence in health care emphasise the importance of developing a good understanding of such obstacles to develop an effective
Transfer of evidence into practice: interventions
The number of original studies and systematic reviews about the effectiveness of different interventions to change clinical practice is growing, which can help in selection of appropriate strategies.38, 39, 40, 41 Main conclusions from an overview of 54 reviews11, 42, 43 are outlined below.
Change is possible when a well-designed intervention is used; most interventions studied had some effects (average of about 10% for main targets). However, none of the interventions is superior for all
Educational strategies
At least nine systematic reviews have addressed distribution of educational materials to professionals (table 2).55, 58, 60, 61, 70, 77, 78, 85, 96 However, the number of studies with enough power, correct analysis, and substantial effects was small, leading reviewers to conclude that the effects of educational materials is limited.60 A systematic review of guideline implementation strategies noted a median improvement of 8% across four cluster randomised trials.11 In view of the feasibility
Interventions aimed at improving hand hygiene
What interventions might be useful to improve hand hygiene practices? We noted one specific systematic review of 22 studies assessing interventions to improve hand hygiene.101 Of these, 15 took place on intensive care units and only three were randomised controlled trials. The main findings (table 3) are outlined below.
Educational interventions (training sessions, newsletters, classes, and videos) were used in 11 studies and seemed to have only a short-term effect on handwashing practice.
Conclusions and messages
Sometimes, the step from best evidence to best practice is simple; however, most of the time it is not, and we need various strategies targeting obstacles to change at different levels, which could even present conflicting values for individual practitioners.100 Therefore, changes in clinical practice are only partly within doctors' control; the prevailing professional and organisational culture towards quality determines the outcome to a large extent.100 Nevertheless, doctors can learn
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