Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Editorial Policies
    • Open Access
  • Content
    • Current Issue
    • Online First
    • Archive
    • Topic/Program Collections
    • Blog
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Editorial Policies
    • Open Access
  • Content
    • Current Issue
    • Online First
    • Archive
    • Topic/Program Collections
    • Blog
  • Subscribe
  • Alerts
  • Careers
American Academy of Pediatrics
Brief Reports

Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative

Sunitha V. Kaiser, Kristin A. Shadman, Eric A. Biondi and Russell J. McCulloh
Hospital Pediatrics November 2019, 9 (11) 903-908; DOI: https://doi.org/10.1542/hpeds.2019-0152
Sunitha V. Kaiser
aDepartment of Pediatrics, University of California, San Francisco, San Francisco, California;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kristin A. Shadman
bDepartment of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Eric A. Biondi
cDepartment of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Russell J. McCulloh
dUniversity of Nebraska Medical Center, Omaha, Nebraska
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Supplemental
  • Info & Metrics
  • Comments
Loading
Download PDF

Abstract

Health care providers’ adherence to guidelines declines over time, and feasible strategies for sustaining adherence have not yet been identified. We assessed the long-term feasibility of various strategies for sustaining guideline adherence and described factors influencing their use. We conducted a cross-sectional survey (N = 104) of physician leaders who participated in a national collaborative to improve care of infants with suspected sepsis. Data were collected on long-term use of strategies to promote guideline adherence (use, perceived effectiveness, and barriers to use). Sixty (58%) participants from diverse hospital settings responded. There were significant declines in use of quality improvement and educational strategies, largely driven by lack of time or staff resources and competing priorities. Electronic strategies (eg, order sets) and hospital policies or guidelines were feasible to continue long-term after the collaborative ended and were perceived as effective. Clinicians and healthcare leaders should consider prioritizing these strategies in their efforts to improve care and outcomes for children in hospital settings.

Health care providers face many challenges adhering to evidence-based guidelines,1 and this poor adherence contributes to poor health outcomes for children in hospital settings.2–4 Effective strategies for promoting providers’ initial adoption of guidelines have been identified (eg, educational meetings, audit and feedback).5 But to reap the full rewards of resources invested into such strategies, we need to also determine how to sustain guideline adherence.6

Guideline adherence often declines over time, but little is known about how to prevent this decline.6,7 A systematic review of sustainability of guideline adherence revealed that only 5 of 14 included studies reported success in sustaining guideline adherence for >1 year, with failures likely due to loss of implementation resources and competing priorities.7 These declines in adherence may especially impact care and outcomes for children because >70% are cared for in general hospitals, where resources tend to be preferentially allocated to adults.8,9

Unfortunately, we have a limited understanding of how to promote robust, sustained guideline adherence and high-quality care.6 Most studies of strategies to improve pediatric guideline adherence have <1 year of follow-up. The few studies with long-term follow-up were done at children’s hospitals, and authors described resource-intensive approaches that included many strategies (electronic order sets, audit and feedback, opinion leaders, and quality improvement [QI] techniques).10,11 Such approaches are unlikely to be feasible across diverse hospital settings, many of which lack a robust QI infrastructure. Identifying feasible, effective strategies for sustaining guideline adherence across diverse settings, including general hospitals, could improve care broadly for all children.

Our objectives for this study were to (1) assess the feasibility of various strategies for sustaining pediatric guideline adherence by using a diverse national sample of hospitals and (2) describe factors influencing the long-term use of these strategies. These findings can help guide future efforts by policymakers, administrators, and health care providers to improve guideline adherence and care for children in hospital settings.

Methods

Study Design, Setting, and Participants

We conducted a cross-sectional study by surveying inpatient physician leaders from hospitals that participated in a national collaborative to improve evidence-based guideline adherence and quality of care for infants with suspected sepsis. Reducing Excessive Variability in the Infant Sepsis Evaluation (REVISE) was led by the Value in Inpatient Pediatrics Network within the American Academy of Pediatrics (AAP).12 A total of 133 hospitals participated in REVISE from December 2016 to November 2017. Multidisciplinary provider teams used several strategies to promote guideline adherence, including educational meetings, clinical pathways, electronic order sets, audit and feedback, a mobile device–based clinical decision-support application,13 and external facilitation (“coaching”) by QI experts. The AAP provided support for these strategies during the collaborative (eg, data platform for audit and feedback, external facilitators).

We surveyed REVISE inpatient physician leaders in October 2018, 11 months after the collaborative ended. The survey was electronically distributed to leaders (N = 104) of sites that completed collaborative activities (REDCap, version 8.10; Vanderbilt University, Nashville, TN). This study was approved by the American Academy of Pediatrics Institutional Review Board.

Data Collection

The survey (Supplemental Fig) was used to collect data on strategies to promote guideline adherence used during the collaborative and continued long-term after the collaborative and associated supports ended. The survey was β-tested and refined by using feedback from a national panel of 10 pediatric hospitalists. Strategies that were asked about included QI strategies (eg, plan-do-study-act cycles), educational and/or training strategies (eg, skills training), electronic strategies (eg, order sets), and organization-level strategies (eg, development of hospital policies). These quantitative data were collected by using “yes or no” questions. In addition, qualitative data were collected on perceived effectiveness and barriers to continued use of these strategies via 2 optional questions (free-text responses): “What strategies helped sustain guideline adherence and high-quality care after the end of the collaborative?” and “Why are these strategies no longer being done [after the collaborative has ended]?”

Outcomes and Analysis

Our primary outcome was use of strategies after the collaborative ended, which was interpreted as long-term feasibility. We compared use rates of each strategy during versus after the collaborative using χ2 and Fisher’s exact tests (when n ≤ 5). We analyzed perceived effectiveness and barriers to continued strategy use by using thematic content analysis (ATLAS.ti, version 7.5.18; Scientific Software Development GmbH, Germany).

Results

Project leaders (N = 104) from 68 children’s hospitals and 36 general hospitals were surveyed, and 60 (58%) responded. There was no difference in response rate by hospital type (P = .75). Hospitals represented all regions of the United States and varied widely in size (4–500 pediatric beds).

Use of Strategies to Promote Guideline Adherence During Versus After the National Collaborative

Strategy use during versus after the collaborative is presented in Table 1. Sites commonly used QI and educational and/or training strategies during the collaborative, with several strategies used by >70% of responding hospitals. Use of these types of strategies declined significantly after the collaborative and associated supports ended.

View this table:
  • View inline
  • View popup
TABLE 1

Strategies to Promote Guideline Adherence Used During Versus After the National Collaborative (N = 60 Hospitals)

Participants commonly reported long-term use of electronic strategies (mobile application, order sets). Approximately half of responding hospitals used these strategies during the collaborative, and these use rates were maintained after the collaborative ended. Use of order sets increased after the collaborative ended.

Long-term use of strategies by hospital type is presented in Table 2. There were no significant differences by hospital type.

View this table:
  • View inline
  • View popup
TABLE 2

Long-term Use of Strategies to Promote Guideline Adherence by Hospital Type

Perceived Effectiveness and Barriers

The majority of participants (n = 45; 75%) provided free-text answers on perceived effectiveness and barriers to continued use of these strategies. The most common themes that were identified and exemplary quotes are presented below and in Table 3.

View this table:
  • View inline
  • View popup
TABLE 3

Perceived Effectiveness and Barriers to Continued Use of Strategies to Promote Guideline Adherence

Perceived Effectiveness

  • Theme 1: Project leaders viewed development of a hospital policy or guideline as helpful in sustaining guideline adherence. Such policies detailed evidence-based recommendations and roles and responsibilities of health care providers.

  • Theme 2: Project leaders described the importance of implementing an electronic order set. Order sets provided clinical decision support in real time as providers managed infants with suspected sepsis.

  • Theme 3: Availability of a mobile application was reportedly helpful in sustaining guideline adherence. This application was developed by the AAP and distributed free of charge. It contained a risk calculator and evidence-based recommendations for management of infants with suspected sepsis.

Barriers

  • Theme 1: Lack of time or staffing was a reported barrier to continued use of strategies to sustain guideline adherence. After the collaborative ended, project leaders no longer had time or staff support to continue data collection and/or monitoring, QI cycles, or educational and/or training meetings.

  • Theme 2: Project leaders also described that competing priorities quickly became a barrier as the collaborative ended and team members were assigned new tasks.

  • Theme 3: Some project leaders described feeling that guideline implementation was complete. This perception contributed to the discontinuation of strategies to sustain guideline adherence.

Discussion

In this national study, we found that electronic strategies and hospital policies or guidelines were the most feasible long-term strategies and were perceived as helpful in sustaining guideline adherence. In contrast, QI and educational strategies to promote guideline adherence declined over time because of many barriers, including lack of time or staffing and competing priorities.

To our knowledge, this is the first multicenter study of feasibility of strategies to sustain pediatric guideline adherence. Previous single-center studies of sustained guideline adherence report intensive approaches that included multiple strategies such as data collection and/or monitoring, audit and feedback, QI methods, order sets, and reminders from local project leaders and/or opinion leaders.10,11 Use of most of these strategies declined significantly over time in our analysis. This may be because we studied a diverse, multicenter, national sample.

We found that most hospitals in our study (63%) did not have a system for monitoring guideline adherence after the collaborative ended, and such monitoring is likely fundamental to ensuring sustained guideline adherence and high-quality care.14 Project leaders reported loss of resources (time, staff) as a top reason for discontinuing data collection and quality monitoring. Loss of resources may be even more common in general hospitals.8 Few hospitals (7%) were able to use electronic strategies for monitoring (eg, reports, dashboards). Such monitoring strategies may require less ongoing time commitment by health care providers (after the initial setup). In future work, investigators should evaluate the feasibility and effectiveness of such strategies.

We also found that electronic strategies (order sets, mobile applications) were feasible to use long-term and that order set use increased over time. This latter finding suggests a long lag time (>1 year) in order set implementation. Authors of previous studies have similarly reported poor technology support and consequent delays in implementing pediatric order sets and other electronic health record modifications such as reports and dashboards.8 Those leading efforts to improve evidence-based care and outcomes for children in hospital settings should consider prioritizing resources for timely implementation of order sets and other electronic health record modifications.10 Future research is needed to understand how to optimize order set design and effectiveness in sustaining guideline adherence and high-quality care.

Our study revealed the use and feasibility of strategies to sustain guideline adherence but not the effectiveness of these strategies. These findings may have differed in hospitals that chose not to participate in this study or those that did not complete collaborative activities (not sampled).

Conclusions

Electronic strategies and hospital policies or guidelines were feasible long-term strategies and were perceived as helpful in sustaining guideline adherence. Those seeking to improve care and outcomes for children in hospital settings should consider prioritizing these strategies. Future research is needed to determine what strategies are most effective in sustaining guideline adherence and high-quality care.

Footnotes

  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • FUNDING: No external funding.

  • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

References

  1. ↵
    1. Cabana MD,
    2. Rand CS,
    3. Powe NR,
    4. et al
    . Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–1465
    OpenUrlCrossRefPubMed
  2. ↵
    1. Silber JH,
    2. Rosenbaum PR,
    3. Wang W,
    4. et al
    . Auditing practice style variation in pediatric inpatient asthma care. JAMA Pediatr. 2016;170(9):878–886
    OpenUrl
    1. Brogan TV,
    2. Hall M,
    3. Williams DJ,
    4. et al
    . Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Pediatr Infect Dis J. 2012;31(10):1036–1041
    OpenUrlPubMed
  3. ↵
    1. Markham JL,
    2. Hall M,
    3. Bettenhausen JL,
    4. Myers AL,
    5. Puls HT,
    6. McCulloh RJ
    . Variation in care and clinical outcomes in children hospitalized with orbital cellulitis. Hosp Pediatr. 2018;8(1):28–35
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Grimshaw JM,
    2. Eccles MP,
    3. Lavis JN,
    4. Hill SJ,
    5. Squires JE
    . Knowledge translation of research findings. Implement Sci. 2012;7:50
    OpenUrlCrossRefPubMed
  5. ↵
    1. Proctor E,
    2. Luke D,
    3. Calhoun A,
    4. et al
    . Sustainability of evidence-based healthcare: research agenda, methodological advances, and infrastructure support. Implement Sci. 2015;10:88
    OpenUrlCrossRefPubMed
  6. ↵
    1. Ament SM,
    2. de Groot JJ,
    3. Maessen JM,
    4. Dirksen CD,
    5. van der Weijden T,
    6. Kleijnen J
    . Sustainability of professionals’ adherence to clinical practice guidelines in medical care: a systematic review. BMJ Open. 2015;5(12):e008073
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Ralston SL,
    2. Atwood EC,
    3. Garber MD,
    4. Holmes AV
    . What works to reduce unnecessary care for bronchiolitis? A qualitative analysis of a national collaborative. Acad Pediatr. 2017;17(2):198–204
    OpenUrlPubMed
  8. ↵
    1. Leyenaar JK,
    2. Ralston SL,
    3. Shieh MS,
    4. Pekow PS,
    5. Mangione-Smith R,
    6. Lindenauer PK
    . Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743–749
    OpenUrlPubMed
  9. ↵
    1. Nkoy FL,
    2. Fassl BA,
    3. Wolfe D,
    4. Colling D,
    5. Hales JW,
    6. Maloney CG
    . Sustaining compliance with pediatric asthma inpatient quality measures. AMIA Annu Symp Proc. 2010;2010:547–551
    OpenUrlPubMed
  10. ↵
    1. Rutman L,
    2. Atkins RC,
    3. Migita R,
    4. et al
    . Modification of an established pediatric asthma pathway improves evidence-based, efficient care. Pediatrics. 2016;138(6):e20161248
    OpenUrlAbstract/FREE Full Text
  11. ↵
    American Academy of Pediatrics Department of Community and Chapter Affairs and Quality Improvement. QI project aims to reduce variability in infant sepsis evaluation. AAP News. May 9, 2018. Available at: https://www.aappublications.org/news/2018/05/09/chapters050918. Accessed March 1, 2019
  12. ↵
    1. McCulloh RJ,
    2. Fouquet SD,
    3. Herigon J,
    4. et al
    . Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project. J Am Med Inform Assoc. 2018;25(9):1175–1182
    OpenUrlCrossRef
  13. ↵
    1. Scoville R,
    2. Little K,
    3. Rakover J,
    4. Luther K,
    5. Mate K
    . Sustaining Improvement. Cambridge, MA: Institute for Healthcare Improvement; 2016
  • Copyright © 2019 by the American Academy of Pediatrics
View Abstract
PreviousNext
Back to top

Advertising Disclaimer »

In this issue

Hospital Pediatrics: 9 (11)
Hospital Pediatrics
Vol. 9, Issue 11
1 Nov 2019
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
View this article with LENS
PreviousNext
Email Article

Thank you for your interest in spreading the word on American Academy of Pediatrics.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative
(Your Name) has sent you a message from American Academy of Pediatrics
(Your Name) thought you would like to see the American Academy of Pediatrics web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Request Permissions
Article Alerts
Log in
You will be redirected to aap.org to login or to create your account.
Or Sign In to Email Alerts with your Email Address
Citation Tools
Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative
Sunitha V. Kaiser, Kristin A. Shadman, Eric A. Biondi, Russell J. McCulloh
Hospital Pediatrics Nov 2019, 9 (11) 903-908; DOI: 10.1542/hpeds.2019-0152

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative
Sunitha V. Kaiser, Kristin A. Shadman, Eric A. Biondi, Russell J. McCulloh
Hospital Pediatrics Nov 2019, 9 (11) 903-908; DOI: 10.1542/hpeds.2019-0152
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Print
Download PDF
Insight Alerts
  • Table of Contents

Jump to section

  • Article
    • Abstract
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Footnotes
    • References
  • Figures & Data
  • Supplemental
  • Info & Metrics
  • Comments

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • Improving Care and Outcomes for Pediatric Musculoskeletal Infections
  • Google Scholar

More in this TOC Section

  • Evaluation and Improvement of Intern Progress Note Assessments and Plans
  • Say What? Quantifying and Classifying Jargon Use During Inpatient Rounds
  • HEADSS Up! Missed Opportunity for Psychosocial Screening in Hospitalized Adolescents
Show more Brief Reports

Similar Articles

Subjects

  • Evidence-Based Medicine
    • Evidence-Based Medicine
  • Administration/Practice Management
    • Quality Improvement
    • Administration/Practice Management
  • Journal Info
  • Editorial Board
  • Editorial Policies
  • Overview
  • Licensing Information
  • Authors/Reviewers
  • Author Guidelines
  • Reviewer Guidelines
  • Submit My Manuscript
  • Open Access
  • Librarians
  • Institutional Subscriptions
  • Usage Stats
  • Support
  • Subscribe
  • Contact Us
  • Resources
  • Media Kit
  • About
  • International Access
  • Terms of Use
  • Privacy Statement
  • FAQ
  • RSS Feeds
  • shopAAP
  • AAP.org
  • Follow American Academy of Pediatrics on Instagram
  • Visit American Academy of Pediatrics on Facebook
  • Follow American Academy of Pediatrics on Twitter
  • Follow American Academy of Pediatrics on Youtube
American Academy of Pediatrics

© 2021 American Academy of Pediatrics