1. Perioperative fasting guideline Getting it into practice Getting started

2. The guideline u Developed using NICE methods, and meeting AGREE criteria. u By an inter-disciplinary guideline development group, including anaesthetist, surgeon, patient, pharmacy, nurse, and dietician representation. u Recommendations made for healthy adults and children, and high risk groups.

3. Getting evidence into practice Getting evidence-based recommendations into practice: IsIs not ComplexLinear ActivePassive Multi-dimensionalRational Context-specificDeductive Evidence Individuals & teams Contexts Change

4. Increasing the chances of success Paying attention to the following may increase the likelihood of success in implementing guideline recommendations: u Having a dedicated project lead u Key stakeholders are identified and fully engaged u Readiness for implementation is assessed.

5. Increasing the chances of success contd... u An implementation action plan is devised and appropriate implementation strategies are used u Progress is evaluated u Resource allocation is considered and appropriate.

6. 1. Identify a project lead u Identify someone to lead the project u For this peri-operative fasting guideline, this person might be a: –Clinical lead (e.g. anaesthetist, nurse, surgeon, dietician) –Quality improvement lead –Practice development nurse

7. 2. Identify & engage key stakeholders u Involve ‘key’ people early u Stakeholders should be representative of those affected by the guideline, and who have a vested interest in it u Clarify and agree roles and contributions u Agree purpose u Set up regular (e.g. monthly) meetings.

8. 3.1 Assessing readiness u Identify where you are now to know what changes are needed u Consider undertaking –Benchmarking –Process mapping –SWOT analysis –Environmental scan u Capture the different perspectives of the stakeholders. Contd…

9. 3.2 Identify barriers A number of barriers may be identified, including: u Communication issues u Some people do not agree with the recommendations. u There is poor team working u Knowledge levels about fasting practice are not up to date u Clinical leaders are not supportive of fasting practice changes u Problems with the organisation of the operating theatre lists. These provide a basis upon which to target implementation strategies

10. 4.1 Develop an action plan u Decide a set of manageable actions u Decide who will do what u Set targets – short, medium and long term u Develop contingency plans u Evaluate progress.

11. 4.2 Indentifying implementation strategies u No single strategy, tool or approach will fit all situations u There is insufficient evidence to say with confidence which strategies work best in a particular context u Need to choose appropriately based on particular people/teams, situation, and readiness assessment findings.

12. 4.3 Implementation strategies the evidence base Generally effectiveSometimes effective Least effective Educational outreach visits Interactive education sessions based on principles of adult learning Targeted multifaceted interventions including 2 or more of the following: Audit & feedback Reminders Local consensus process Marketing  Audit & feedback  Local opinion leaders  Local consensus process  Patient mediated interventions  Dissemination using education  Didactic educational meetings Grimshaw et al (2004)

13. 4.4 Other ideas for implementing the perioperative fasting guideline u Getting the message across: ‘2 – 6 rule’ – healthy adults can drink clear fluids until 2 hours before anaesthesia, and can eat food until 6 hours before anaesthesia –Use notice boards and internal media to publicise –Hold interactive education sessions involving all staff affected by this practice –Get clinical leads to champion the message within and across the various disciplines.

14. Ideas for implementation contd… u Develop an integrated care pathway reflecting the ‘ideal’ patient journey from pre-assessment to post- operation u Implement plan-do-study-act methods to identify current practice, changes required, make changes, monitor effects u Deliver interactive education sessions, which include problem-based, context realistic, scenarios.

15. 5.1 Evaluate progress u Develop an evaluation plan before going ahead with implementation u Keep it simple u Include structure, process and outcome indicators (see next slide for examples) u Devise feedback mechanisms so people know how things are going.

16. 5.2 Indicators of progress u Structure, process and outcome: –Structure e.g. availability of food –Process e.g. staff knowledge about new fasting practice –Outcome e.g. what is patient’s fasting time pre- and post-operatively? u Compare pre- and post- implementation changes u Check whether changes have been sustained a few months later.

17. 5.3 Approaches to evaluation u Audit and feedback u Interviews with staff u Short questionnaire u Discussions with patients*. *need to consider ethical implications

18. 6. Resources u Financial, human or in-kind requirements necessary to achieve targets in the action plan u These need to be considered in the early stages, and continually monitored u Involve finance and human resource representatives in the planning stages.

19. Top 10 tips u Get key stakeholders on board u Keep stakeholders engaged u Identify a dedicated project lead u Decide on implementation strategies that are relevant to the context and people who will be using the guideline u Devise an action plan and regularly evaluate progress.

20. Top 10 tips contd… u Identify and allocate resources appropriately. u Get the 2-6 message across! u Use posters u Use local clinical champions u Focus efforts on the experience of patients.

21. Some downloadable resources u RNAO – Implementation of clinical practice guidelines toolkit – http://www.rnao.org/Page.asp?PageID=924&Content ID=823 u National Institute for Health & Clinical Excellence implementation resources - http://www.nice.org.uk/page.aspx?o=tools u NHS sustainability model & guide - http://www.institute.nhs.uk/NR/rdonlyres/9E4B7EA0- C338-4F35-9FE4- D797C704B986/0/ST_SECTION01.pdf