PHASE 1: EXPLORATION

Identifying human factors and environmental factors

Prior to implementation, it is necessary to establish a good understanding of the human factors and environmental factors within which the implementation will happen. Factors to be considered are:

  • if there is an internal need for change,
  • the types of interventions available,
  • who might be on the team for implementation,
  • general views from the staff about the changes,
  • needs of the patients,
  • if funding is needed and available, and
  • whether the organisation is ready for change.


Select any of the following categories to continue:

Identify Internal Needs
Intervention
The Team
Staff
Readiness for Change
Funding
Patient

Identify Internal Needs

Here we use PONV as an example:


How is PONV prevented and managed within the local hospital?

  • This can be found from the hospital practice guidelines for PONV.


Is PONV incidence charted in the observation chart or record?

  • It is necessary to check various charts to see if PONV is charted at any stage, including Recovery, on the ward or pre-discharge for day surgery patients.


What is the current PONV incidence and rate of post-operative (rescue) antiemetics use?

  • This will help determine the current need. Then a study to follow up patients is needed. Alternatively simply check rates of rescue anti-emetic use. However rescue anti-emetic use is not equivalent to PONV.
  • You may use this questionnaire to chart the PONV.


Is PONV risk assessed?

  • PONV risk assessment is the first recommendation for PONV management (Gan 2014).
  • PONV risk factors are often not documented.
    • Four factors: female, non-smoker, previous PONV or motion sickness for those who have not had surgeries before, and post-operative opioid use. For every additional factor, the risk increases by 20% (Apfel et al., 1999).
  • Documentation of the risk help anaesthetists to develop PONV management plan tailored to individuals.
  • If PONV risk is not assessed, you may use this checklist, designed for patients to check their own risk and present it to nurses.

Intervention

This diagram illustrates various modes of acupuncture or acupressure that have been tested in clinical trials to reduce PONV. It shows the pros and cons of each intervention. Data of effectiveness are also presented. Please click on the intervention to learn more.

Types of Acupuncture/Acupressure

The Team

In this step, the team for implementation is identified. Team members include opinion leaders, champions or drivers and external change agents. This is related to the Engaging domain under Process within the CFIR. https://cfirguide.org/constructs/engaging/. Forming the team with the right people is an important step that should be considered at the exploration phase. In addition, engaging the management and the end users is also part of the role of the team. Implementation is more likely to be successful if the early users are similar to the leaders in terms of their professional, education, cultural and / or socio-economic background (Greenhalgh et al., 2004).

  • Opinion leaders / facilitators are “Individuals in an organization who have formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the intervention” or those “who have been formally appointed with responsibility for implementing an intervention as coordinator, project manager, team leader, or other similar role.”
  • Champions are individuals who “drive through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization”
  • External change agents are individuals who are external to the organisation but “formally influence or facilitate intervention decisions in a desirable direction.”

Staff

Staff refers to those who will carry out the implementation. In the peri-operative setting, this refers to anaesthetists, nurses, midwives, gynaecologists and obstetricians, surgeons, clerks, and interpreters; ie, all members involved peri-operatively.

Prior to implementation, staff attitudes to, and knowledge of, acupuncture / acupressure should be ascertained. An USA survey of anaesthesiologists and anaesthesia assistants found they supported the use acupuncture/ acupressure in surgical patients. A similar survey was conducted among anaesthetists, midwives, gynaecologists and obstetricians, nurses and surgeons in an Australian hospital.  Strong support for using acupuncture / acupressure for post-operative nausea and vomiting was found. Please find the sample survey question here.

Results of a USA Survey

A recent survey from the USA examined the perception of acupuncture and acupressure of 1,728 anaesthesia staff in 96 anaesthesiology departments (Faircloth, 2014). Of the 292 respondents (17% response rate), 54% were anaesthesiologists, 44% nurses and 2% anaesthesia aiders. Although only 27% of those surveyed had used acupuncture or acupressure with positive outcomes, 54% of the respondents said they would consider using acupuncture or acupressure. Moreover, 74% of those surveyed would consider having acupuncture or acupressure education. The main barriers to implementing this therapy were “lack of scientific evidence” (79%), including mechanisms and results of clinical trials in humans, “unavailability of credentialed providers” (71%), and “lack of equipment” (49%). Only 38% considered acupuncture as being too time consuming to perform.

Results of a survey of doctors, nurses, mid-wife and obstetricians in an Australian hospital

42% of 165 respondents believed acupuncture / acupressure was effective for PONV. After being told this non-drug therapy was effective for PONV, 81% would encourage patients to use acupuncture / acupressure for PONV if it was offered at the hospital, and 88% wanted to have further education about this form of therapy.  For further information, please contact the administrator of this website.

Acceptance of acupuncture by Australian doctors

Although no such a survey has been conducted in Australia nationally, it is likely that similar themes will be seen here. In Australia, acupuncture is well-accepted by general practitioners. A national survey of 544 general practitioners found that about 85% considered acupuncture to be effective and safe for primary care (Cohen et al., 2005).  80% of GPs have referred their patients to have acupuncture (Wardle et al., 2013).  Some medical schools in Australia teach acupuncture as an elective course. That acupuncture is not foreign to Australia medical staff provides a strong basis for implementing and integrating acupuncture into the healthcare system.

Assessment of Readiness for Change

 

The Checklist to Assess Organization Readiness (CARI) (Barwick, 2011) assesses the readiness of the system, support from the senior leadership, staff capability, the maturity of the implementation plan and training needed for implantation. The total score for this modified CARI will be 100 points.  A CARI total score of 80 points, with each category at least 15 points, will be considered to show that the organisation is ready for implementation.

Modified CARI Checklist

Cost and Funding

It is necessary to consider the current cost of acupuncture / acupressure including the cost of the device and of the staff time, and whether this is cost neutral or cost-saving. Please see the table for details (Myle P, 2016)

Types of Costs and How to Track it (Myle 2016)

CostsAssessment Tools
• Cost of the device per patient
• Time needed to deliver the intervention
• Time needed to monitor the intervention
• Antiemetic medication used (prevention and rescue)
• Cost of antiemetic medications
• Pain medication used intra and post-operatively
• Cost of pain medication used 		• Track time (minutes) needed for acupuncturist to deliver the intervention
• Track the type and dose of anti-emetic medication used
• Track the type and dose of pain medications used

Cost
• Calculate the cost of antiemetic medications
• Calculate the cost of pain medications
• Calculate the cost of device

Patient

Patients’ needs and willingness should be assessed or understood.  PONV management guidelines recommend considering patient preferences when choosing interventions.

An Australian survey (Weeks et al., 2017) of 160 patients shows that 65% of surgical patients would be willing to use acupuncture for post-operative nausea and vomiting, although only 15% of them knew acupuncture could be used to treat nausea and vomiting. After being told the effectiveness of acupuncture, the percentage of patients who were willing increased to 87%.

Please find the publication and sample patient survey here.   

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