Continuous Quality Improvement Of The Evidence-based Practice Project For Identification And Management Of Stroke Dysphagia: An Implementation Study

Background:Stroke is one of the main detrimental diseases with high incidence,high morbidity and high mortality rate.Dysphagia is one common and severe symptom of post-stroke.Patients with post-stroke dysphagia often suffer from a series of severe complications,like aspiration pneumonia,bronchopulmonary infection,declined quality of life etc.While nurses,guided early identification and management of dysphagia can significantly reduce the incidence of fatal complications and improve patients' quality of life.Our team has led a guideline-based evidence implementation project on post-stroke dysphagia identification and management in 2015 in one tertiary hospital in Beijing China,and has got short-term success.While our survey towards this project after one-year implementation found that,the adherence of audit items has declined and some even didn't sustain.In order to sustain the innovation achievements and improve nursing quality continuously,we need to investigate the status quo of this project;analyze factors influencing its sustainability;develop and implement action plans to promote its sustainability.Objectives:Understand the sustainability status of this project;Analyze factors influencing the project sustainability;Develop and implement corresponding action plan to improve patients' outcomes,nurses' knowledge and evidence-based nursing capacity,and build organizational evidence-based nursing culture.Methods:This implementation research takes evidence-based continued quality improvement framework as the guiding framework and refers to the National Health Service Sustainability Model.Take the project implementation ward(including nurses,patients,doctors,department flow chart,record sheet,etc.)as the research object.Firstly,understand the sustainability status of the project with observation,interview and knowledge test and analyze factors influencing its sustainability with interview and questionnaire.Then based on the combination of best available evidence,influencing factors on sustainability and expert consensus meeting,develop Post-stroke dysphagia identification and management project sustainability action plan(including the updated evidence-based practice protocol and sustainability promotion plan).Implement the action plan and evaluate the outcome from patients',nurses' and organizational perspective.Results:?Within the 12 audit items,the implementation rate of project sheets and document relevant audit items 2,5,7 and 8 were 100%;project practice relevant audit items 1,4 and 6 were merely 26.67%,0%,0%;operative skills,training and knowledge relevant audit items 3,9 and 10 were 75.00%,37.50%and 12.50%respectively;health education to patients and their family members(caregivers)relevant audit items 11 and 12 were both 33.33%.The whole implementation rate had decreased significantly.The factors influencing program sustainability include program characteristics:necessity,priority,completeness and fitness;organizational environment:human resource,training and publicity,infrastructure and quality monitoring system;Sense of collaboration:nurse-patient collaboration,nurse-doctor collaboration,clinician-researcher collaboration.? Six evidence-based guidelines were included to the action plan development.The dysphagia screening time,screening tool,treatment method,graded dysphagia management protocol and nutritional risk screening tool were adjusted or added to the previous evidence-based practice protocol.We developed the Standardized Swallowing Assessment(SSA)sheet,NRS2002 nutritional risk screening sheet,graded dysphagia management protocol,revised the nurses' knowledge manual and patients'health education manual,modified the warning board,and developed the action strategies to promote project sustainability.?We implemented the action plan with steps of team building,kick-off meeting,pre-practice preparation,clinical practice and project specialized quality monitoring etc.? The score of SSA test,knowledge test,swallowing-quality-of-life(SWAL-QOL)were improved with statistical significance(p>0.05).Patients' hospitalization satisfaction also raised.There was no significant difference in patients,length of hospital stay and nutritional status(p>0,05).Nurses' knowledge and evidence-based nursing ability were significantly increased(p<0.05).In the organizational level,the sheets,manuals,leaflets developed were fully used and were all stored in the printed and electronic version of post-stroke dysphagia knowledge database.The project sustainability improved significantly.This project improved nurses' crticial thinking,awareness of evidence-based concept and research collaboration concept,promoted the introduction of evidence-based nursing concept and evidence-based practice achivements for wards nearby,and the organization had also begun to create an evidence-based atmosphere,increase investment,promote cooperation and disseminate the achievements.At the same time,the project provided a reflection on the integration of nursing specialization-specialized nurses-specialized nursing quality improvement.Conclusions:?The sustainability of this evidence implementation project---post-stroke dysphagia identification and management is poor.Program characteristics(necessity,priority,completeness and fitness),organizational environment(human resource,training and publicity,infrastructure and quality control system)and sense of collaboration(nurse-patient collaboration,nurse-doctor collaboration,and clinician-researcher collaboration)are factors influencing project sustainability.?In the process of evidence-based practice,the action plan should be updated and optimized with the consideration of clinical status and the best availble evidence.In addition,develop strategies to promote project sustainability according to its influencing factors.? In the project implementation process,we should regard the implementation team as the project main body,fully mobilize their enthusiasm,and adjust or revise the action plan according to specific clinical problems.?The continuous quality improvement of this evidence-based practice project can improve patients' swallowing function,quality of life,hospitalized satisfaction and knowledge level;promote the improvement of nurses' knowledge level and evidence-based nursing ability;enhance the project sustainability and the evidence-based culture for the organization,and provide thought for "specialization-specialized nurse-specialized nursing quality control".