Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England

Abstract

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.Setting and participantsThree secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).AnalysisQualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation.ResultsParticipants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).ConclusionsClinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development

“…[ 40 ]. Example : Feedback was never provided to staff on the effect of the AKI e-alert “I haven’t had any feedback since the new version (of the AKI e-alert) went in actually(...) I don’t know whether there is a formal mechanism for that getting to anyone”’ [ 52 ]. Communal appraisal [ 7 ] Description: How do people collectively assess interventions and their components as worthwhile?…”

“…“Most people I'm sure would know it's a good idea having them. That's what I'd say to someone about these alerts”’ [ 52 ]. Individual appraisal [ 7 ] Description: How do people individually assess interventions and their components as worthwhile?…”

“…Example : Feedback was never provided to staff on the effect of the AKI e-alert “I haven’t had any feedback since the new version (of the AKI e-alert) went in actually(...) I don’t know whether there is a formal mechanism for that getting to anyone”’ [ 52 ].…”

“…“Most people I'm sure would know it's a good idea having them. That's what I'd say to someone about these alerts”’ [ 52 ].…”

Prior to Implementation of Digital Pathology—Assessment of Expectations among Staff by Means of Normalization Process Theory

“…The NoMAD is a validated questionnaire for use when measuring implementation processes from the perspective of professionals involved in the implementation with interventions in healthcare [ 22 , 23 ]. The NPT is an internationally recognized theory of implementation [ 24 ] that focusses on the understanding of how interventions become integrated in the daily workflow through implementation. The theory focusses on four core constructs, as follows: coherence, cognitive participation, collective action, and reflexive monitoring, through which the integration is proposed to occur [ 22 , 24 , 25 , 26 ].…”