The POISE study
What is the best approach to implementing guidelines?
POISE is an acronym for the peri-operative fasting guideline implementation study evaluation project. The Royal College of Nursing in collaboration with the Royal College of Anaesthetists conducted a national research study during 2006 to 2009 evaluating guideline implementation strategies. Nineteen acute trusts across the four countries of the UK participated in the study, “one of the first national randomised controlled trials conducted with acute care in implementation research”.
The objective of the study was to evaluate three strategies for the implementation of the guideline recommendations on perioperative fasting presented in this resource. The guideline aimed to address inconsistencies in preoperative fasting times despite the evidence for the benefits of shortened preoperative fasting.
The study was a pragmatic cluster controlled trial (RCT) using time series with embedded mixed methods process and economic evaluation. Hospitals were randomised to one of three interventions:
- standard dissemination (SD) of a guideline package
- standard dissemination plus a web-based resource championed by an opinion leader
- standard dissemination plus the plan-do-study-act (PDSA) quality improvement model.
Data on fasting were collected four times pre-intervention and four times post-intervention. The study also involved interviews of patients in each trust pre-intervention and post-intervention to gain their experience of fasting practice. Staff experiences were also gathered.
Article on the POISE study
POISE was a large, complex study and a “rich picture of the implementation challenges emerged”. An article about the study can be read in full on the Implementation Science website:
Rycroft-Malone J et al (2012) A pragmatic cluster randomised trial evaluating three implementation interventions, Implementation Science 7:80 doi:10.1186/1748-5908-7-80.
A related article is Rycroft-Malone J et al (2013) The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework, Implementation Science 8:28 doi:10.1186/1748-5908-8-28.
Summary of key points from POISE
- There were no significant differences in fasting times between pre to post intervention, or between the different implementation interventions.
- Process data revealed different types of impact, including changes to practices, policies and attitudes.
- Implementation challenges included inter-professional tensions and lack of clarity for decision making authority and responsibility.
- Changes to practice need to be an organisational priority so that resources, including human and financial, are prioritised. In the case of PoISE, whilst fasting times were important to some practitioners, reducing fasting times was generally not a priority for the organisation.
- Facilitators require people management skills, including the ability to
- work collegially,
- work collaboratively
- work inter-professionally (may require sharing facilitation role between professions)
- handle difficult situations and people with diplomacy
- understand where people ‘are coming from’
- develop and motivate a team, including effective and considerate delegation of work, using team members skills well. - Nine propositions have been developed that reflect the conditions and antecedents for implementation.
For further details see the article above.