Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
Department of Internal Medicine, Nursing Science, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Implement Sci. 2020 May 25;15(1):38. doi: 10.1186/s13012-020-00995-z.
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.
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 de-implementation 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.
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 low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation 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).
The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used.
The review is registered in Prospero (CRD42018105100).
在过去十年中，人们越来越关注检测和编制低价值护理程序清单。然而，对于这些程序的有效实施策略知之甚少。因此，本系统评价的目的是总结有效实施策略以消除低价值护理程序的证据。
截至 2020 年 1 月，我们对 PubMed、Embase、Emcare、CINAHL、PsycINFO、Cochrane 对照试验中心注册库、Web of Science 和 Google Scholar 进行了检索。此外，还检索了纳入研究的参考文献和引文。本研究纳入了描述低价值护理程序消除的研究，即护士或护士从业者实施的程序、测试或药物医嘱。我们遵循了 PRISMA 指南，并使用“Cochrane 有效实践和组织护理”（EPOC）分类法对消除策略进行了分类。对对照研究中低价值护理程序的数量进行了荟萃分析，并使用随机效应模型计算了 Mantel-Haenszel 风险比（95%CI）。
本综述共纳入 27 项研究。研究使用（聚类）随机设计（n = 10）、对照前后设计（n = 5）和非对照前后设计（n = 12）。本研究发现护士和/或护士专家实施的低价值护理程序包括：约束使用（n = 20）、不适当的抗生素处方（n = 3）、留置或不必要的导尿管使用（n = 2）、不必要的肝功能检查（n = 1）和不必要的抗精神病药物处方（n = 1）。14 项研究显示低价值护理程序显著减少。其中 14 项研究中的 13 项在其消除策略中包含了教育内容。对 12 项对照研究进行了荟萃分析。研究设计的亚组分析显示，低价值护理程序的数量无统计学显著亚组效应（p = 0.20）。
大多数具有积极显著效果的研究使用了包含教育内容的消除策略。不幸的是，由于高度异质性和缺乏研究，我们无法得出哪种策略最能有效减少低价值护理的结论。我们建议未来的研究更好地报告消除策略的效果，并进行过程评估，以确定策略的使用程度。
本综述已在 Prospero（CRD42018105100）中注册。
