Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis

Abstract

Background: In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. Methods: PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the 'Cochrane Effective Practice and Organisation of Care' (EPOC) taxonomy was used to categorize deimplementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel-Haenszel risk ratios (95% CI) were calculated using a random effects model. Results: Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in lowvalue nursing procedures. Thirteen of these 14 studies included an educational component within their deimplementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20).

De-implementation and substitution of clinical care processes: stakeholder perspectives on the transition to primary human papillomavirus (HPV) testing for cervical cancer screening

“…An example of the reduction in frequency is the evolving guideline recommendation to extend the intervals between cervical cancer screenings for low-to-average risk women. Many current de-implementation efforts in cancer care and other clinical disciplines stem from the Choosing Wisely campaign from the American Board of Internal Medicine, which focuses on clinical practices that could be reduced or completely ceased across a variety of clinical domains [ 13 , 23 – 26 ].…”

De-implementation and Substitution of Clinical Care Processes: Stakeholder Perspectives on the Transition to Primary Human Papillomavirus (HPV) Testing for Cervical Cancer Screening

“…Many current de-implementation efforts in cancer care and other clinical disciplines stem from the Choosing Wisely campaign from the American Board of Internal Medicine, which focuses on clinical practices that could be reduced or completely ceased across a variety of clinical domains. (18)(19)(20)(21)(22) In contrast to de-implementation, substitution has been de ned as the promotion of one or more alternatives to an ineffective or less effective practice, in which the substitutes replace or displace the previous practice. ( [23][24][25][26] Ideally, to ease cognitive pressures and potentially simplify change management strategies, a substitution will have a related replacement that is a similar, closely related but more effective intervention.…”

Out with the Old and in With the New: Deimplementation in Emergency Medicine

“…We would be well suited to study deimplementation efforts from other fields, including both successes and failures. Low‐value nursing procedures have been the subject of many deimplementation projects, including a systematic review and meta‐analysis 7 . However, only 14 of the 27 included studies were effective in deimplementing low‐value practices 7 .…”

“…Low‐value nursing procedures have been the subject of many deimplementation projects, including a systematic review and meta‐analysis 7 . However, only 14 of the 27 included studies were effective in deimplementing low‐value practices 7 . The vast majority (13 of 14) of the successful studies included an educational component in their deimplementation strategy 7 .…”

“…However, only 14 of the 27 included studies were effective in deimplementing low‐value practices 7 . The vast majority (13 of 14) of the successful studies included an educational component in their deimplementation strategy 7 . Indeed, the educational Choosing Wisely campaign (http://www.choosingwisely.org) of the American Board of Internal Medicine has spawned several studies from multiple disciplines.…”