Background Variable standards of care may contribute to poor outcomes associated with AKI. We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program) would improve delivery of care and patient outcomes at an organizational level. Methods A multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals, involving patients with AKI aged $18 years. The intervention was introduced sequentially across fixed three-month periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was 30-day mortality, with pre-specified secondary endpoints and a nested evaluation of care process delivery. The nature of the intervention precluded blinding, but data collection and analysis were independent of project delivery teams. Results We studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference between control and intervention periods. Hospital length of stay was reduced with the intervention (decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment of process measures in 1048 patients showed improvements in several metrics including AKI recognition, medication optimization, and fluid assessment. Conclusions A complex, hospital-wide intervention to reduce harm associated with AKI did not reduce 30-day AKI mortality but did result in reductions in hospital length of stay, accompanied by improvements in in quality of care. An increase in AKI incidence likely reflected improved recognition.

Purpose -The purpose of this study is to examine important operational issues related to strategic success factors that are necessary when implementing SCM plans in an organization. Design/methodology/approach -A questionnaire was distributed to top and middle management within a large manufacturing firm, specializing in producing consumer and building products, to examine the importance and the extent to which the selected manufacturing company practiced the strategies based on these identified operational issues. Findings -Reducing cost of operations, improving inventory, lead times and customer satisfaction, increasing flexibility and cross-functional communication, and remaining competitive appear to be the most important objectives to implement SCM strategies. The responses by the survey respondents indicate that not enough resources were allocated to implement and support SCM initiatives in their divisions. In addition, they perceived that resource allocation could be improved in the areas of better information systems, greater commitment, setting clear-cut goals, increased training, more personnel, and aligning SCM initiatives with current priorities and resource commitments. Practical implications -The results will help to provide greater understanding of strategic and operational issues that support SCM framework and implementing SCM strategies to reduce supply chain-wide costs and meeting customer service levels. Originality/value -The results will be useful for business managers to understand and implement SCM plans in terms of their importance and the company's culture.

Diverse community primary care practices without support from health system resources will complete participation in complex trials. Researchers need not avoid answering questions requiring complex study designs; however, successful implementation requires an individualized approach tailored to the needs and characteristics of each practice.

BackgroundAcute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported.Methods29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted.ResultsInterviews generated four ‘barriers and enablers’ to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators.ConclusionsDespite diversity of sites, a range of common local factors–contextual, intervention-based and individual–were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives.

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