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Background: Clinicians are often familiar with quality improvement (QI) and evidence-based practice (EBP) processes, which provides guidance into what evidence should be implemented; however, these processes do not address how to successfully implement evidence., Objective: Clinicians would benefit from a deeper understanding of implementation science, along with practical tools for how to use these principles in QI and EBP projects., Methods: We provide a brief background of the principles of implementation science, an overview of current implementation science models and a toolkit to facilitate choosing and using common implementation science strategies. In addition, the toolkit provides guidance for measuring the success of an implementation science project and a case study showing how implementation science strategies can be used successfully in clinical practice., Conclusions: Using an implementation science toolkit for designing, conducting, and evaluating a QI or EBP project improves the quality and generalizability of results., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care., Objective: To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care., Design, Setting, and Participants: This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020., Interventions: Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website., Main Outcomes and Measures: The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed)., Results: Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21])., Conclusions and Relevance: Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score., Trial Registration: ClinicalTrials.gov Identifier: NCT03035474.

Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date., (Copyright © 2019. Published by Elsevier Inc.)

Clinical decision support systems are used to ensure compliance with guidelines and can assist providers in improving quality of care. This quality improvement initiative was designed to evaluate the use of a clinical decision support system to improve specialist referral rate for patients with severe aortic stenosis. A clinical decision support system for cardiology and primary care providers was implemented to improve diagnosis of severe aortic stenosis. The ordering provider received an electronic medical record in-basket alert providing feedback and recommendations for referral to specialist for evaluation. The echocardiogram data were evaluated for change in specialist referral rate. Before clinical decision support system implementation, the referral rate was 72% for a 3-month period. All providers ordering echocardiograms received clinical decision support system notification if patient results met criteria based on valve severity (aortic valve area < 1.0 cm, mean gradient ≥ 40 mm Hg, peak velocity ≥ 4.0 m/s). After implementation, clinical decision support system referral rate was 97.5%, a 24.6% increase in referral rates (P < .001). Low referral rates for patients with severe aortic stenosis are a recognized challenge. Utilizing the clinical decision support system to improve awareness of quality guidelines and recommendations was associated with increased adherence to referral guidelines by providers. This innovation is pertinent to practice and enhances the functionality of the electronic medical record by providing real-time feedback to providers to improve practice. Referral rates for patients with severe aortic stenosis can be improved with use of provider clinical decision support system.

Background: Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others. Local Problem: Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients. Methods: A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model. Interventions: A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs. Results: Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (−20.3 mm Hg; P >.001). Conclusions: This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).Methods and Results: Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27-6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59-0.97]; P = 0.027).Conclusions: Among participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation. [ABSTRACT FROM AUTHOR]

Treatment options for patients with heart failure have improved rapidly over the last few decades. Data from large scale clinical trials demonstrate that medical and device therapies can improve quality of life, reduce hospitalizations for acute heart failure, and reduce mortality. However, the use of many of these therapies in routine practice is remarkably low. There are many reasons for suboptimal implementation of evidence‐based therapies for heart failure, and we believe addressing the large gap between what can be accomplished in clinical trials versus routine practice is a critical and urgent public health issue. In this review, we outline reasons for this implementation gap and review recent studies attempting to address this issue. We also provide recommendations for future interventions and areas of clinical investigation to improve implementation for patients with heart failure. [ABSTRACT FROM AUTHOR]

Doctor of Nursing Practice programs prepare nurse leaders for unique roles to address healthcare needs across the quality spectrum. However, additional mentoring and training in implementation science and analytical skills is needed to effectively lead system-wide quality initiatives. The purpose of this article is to describe the planning, implementation, and evaluation of an innovative post-doctoral DNP Quality Implementation Scholars Program developed through an academic-practice partnership to address this need. Throughout the one year post-doctoral program, we evaluated student experiences qualitatively using focus groups and quantitatively using standardized course and instructor surveys to assess overall programmatic goals. Program outcomes were evaluated from the perspective of the academic-practice partnership planning committee through a Qualtrics© survey. Strengths of the program included the in-depth mentoring by faculty and relationships built across the larger health system. Both scholars and the planning team noted that the system-wide project implemented by the scholars was relevant, timely, and quality-focused. This innovative DNP post-doctoral program leveraged the skill-sets of DNP-prepared nurse leaders to lead system-wide quality improvement initiatives tailored specifically to healthcare organizations. • DNP-prepared leaders require extra mentoring to lead large system-wide quality initiatives. • A DNP post-doctoral program was developed through an academic-practice partnership. • A cohort of four DNP nurses completed the one year program to improve QI skills. • Faculty and health system leaders provided in-depth mentoring through the program. • Scholars completed a system-wide QI project that resulted in reduced patient harm. [ABSTRACT FROM AUTHOR]

Introduction: Patients hospitalized for heart failure (HF) are at an increased risk of rehospitalization and death following discharge. However, limited data exist to inform health systems on implementation of evidence-based quality improvement (QI) initiatives for the peri-discharge period. Methods: The CONNECT-HF trial is an ongoing, large-scale, pragmatic, cluster-randomized trial designed to evaluate the effect of a health-system level QI intervention compared to usual care on HF outcomes in the United States. Eligible hospitals were required to have the capacity to be randomized to a system-based QI intervention. We conducted a web-based survey of participating hospitals in the United States between June 1, 2017 and May 23, 2018 by asking QI leaders at each site to complete a questionnaire describing the site's baseline hospital-based QI practices. Results: Of 114 hospitals, 55% reported admitting most patients (>50%) diagnosed with decompensated HF to specialized HF units or care teams (Figure). Of participating hospitals, 56% have a system for various pre-discharge assessment and actions. For patients with HF who cannot see their primary provider within 7-10 days, 60% of hospitals have a post-discharge clinic to assist with the post-discharge transition, and 65% have clinics that can accommodate same-day or unscheduled outpatient HF visits. In terms of QI resources, 76% of hospitals have a QI team that focuses on HF care, and 45% participate in a government-sponsored or national professional society HF QI program. Conclusion: At baseline time of inclusion in the CONNECT-HF trial, wide variations in hospital care, discharge processes, outpatient follow-up, and QI participation among participating hospitals were identified. This suggests ample opportunity for continued refinement and improvement of HF care even among a proactive group of hospitals meeting criteria for enrollment in a trial of transitional care. [ABSTRACT FROM AUTHOR]

Background and Objectives: Central line–associated bloodstream infections (CLABSIs) are a common, preventable healthcare–associated infection. In our 3-hospital health system, CLABSI rates in non-intensive care unit (ICU) settings were above the internal target rate of zero. A robust quality improvement (QI) project to reduce non-ICU CLABSIs was undertaken by a team of Doctor of Nursing Practice (DNP)-prepared nurse leaders enrolled in a post-DNP Quality Implementation Scholars program and 2 QI experts. Based on a review of the literature and local root cause analyses, the QI team implemented the evidence-based practice of using 2% chlorhexidine gluconate (CHG) cloths for daily bathing for non-ICU patients with a central line. Methods: A pre-post-design was used for this QI study. CHG bathing was implemented using multifaceted educational strategies that included an e-learning module, printed educational materials, educational outreach, engagement of unit-based CLABSI champions, and an electronic reminder in the electronic health record. Generalized linear mixed-effects models were used to assess the change in CLABSI rates before and after implementation of CHG bathing. CLABSI rates were also tracked using statistical process control (SPC) charts to monitor stability over time. CHG bathing documentation compliance was audited as a process measure. These audit data were provided to unit-based leadership (nurse managers and clinical team leaders) on a monthly basis. A Qualtrics survey was also disseminated to nursing leadership to evaluate their satisfaction with the CHG bathing implementation processes. Results: Thirty-four non-ICU settings participated in the QI study, including general medical/surgical units and specialty areas (oncology, neurosciences, cardiac, orthopedic, and pediatrics). While the change in CLABSI rates after the intervention was not statistically significant (b = −0.35, P =.15), there was a clinically significant CLABSI rate reduction of 22.8%. Monitoring the SPC charts demonstrated that CLABSI rates remained stable after the intervention at all 3 hospitals as well as the health system. CHG bathing documentation compliance increased system-wide from 77% (January 2020) to 94% (February 2021). Overall, nurse leaders were satisfied with the CHG bathing implementation process. Conclusions: To sustain this practice change in non-ICU settings, booster sessions will be completed at least on an annual basis. This study provides further support for using CHG cloths for daily patient bathing in the non-ICU setting. [ABSTRACT FROM AUTHOR]